4. Benign Paroxysmal Position Vertigo
A deep learning model for three-dimensional nystagmus detection and benign paroxysmal positional vertigo diagnosis
Wen Lu1, Yini Li1, Zhuangzhuang Li1, Jie Li1, Zhengnong Chen1, Yanmei Feng1, Hui Wang1, Qiong Luo1, Dongzhen Yu1, Haibo Shi1, Shankai Yin1
1Department of Otolaryngology Head and Neck Surgery, Shanghai Sixth People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, China
Purpose: To design a three-dimensional nystagmus recognition model and a benign paroxysmal positional vertigo utomatic diagnosis system based on deep neural network architectures.
Methods: An object detection model was constructed to track the movement of the pupil centre. Convolutional neural network-based models were trained to detect nystagmus patterns in three dimensions (horizontal/vertical/torsional) using clinic videos from 854 patients, including 3496 videos for horizontal nystagmus and 5962 videos for vertical/torsional nystagmus. Finally, the statistical metrics generated during model predictions were calculated for automatic benign paroxysmal positional vertigo diagnosis. An independent test set of 502 cases, generated from 457 patients, was used to evaluate the overall performance of the diagnosis system.
Results: Our nystagmus detection models obtained high areas under the curve; 0.982 in horizontal tests, 0.893 in vertical tests, and 0.957 in torsional tests. Compared with previous studies, our nystagmus model was comparable and interpretable. Moreover, our automatic benign paroxysmal positional vertigo diagnosis system achieved a sensitivity of 0.8848, specificity of 0.8841, accuracy of 0.8845, and an F1 score of 0.8914.
Conclusions: Our system provides a clinical reference and facilitates nystagmus detection and diagnosis, and it can be applied in real-world medical practices.
A Nystagmus-Based Approach: Minimum Stimulus Strategy and Its Latest News
Salvatore Martellucci1, Fernanda Asprella Libonati2, Giacinto Asprella Libonati3
1Otorhinolaryngology Unit, Santa Maria Goretti Hospital, AUSL, Latina, Italy
2Indipendent Researcher Rome Italy
3Giovanni Paolo II Hospital Policoro MT Italy
Purpose: The aim of this work is to present a strategy for approaching BPPV that is minimally invasive and well tolerated by the patient.
Methods: BPPV diagnosis should be based on the step-by-step observation of the evoked nystagmus. The Minimum Stimulus Strategy (MMS) aims to minimize the patient's discomfort. The Upright BPPV Protocol (UBP), has recently been proposed as an implementation of MSS, it is a diagnostic approach to BPPV conducted in the sitting position slowly bending the patient's head along the spatial axes, aiming to move canaliths by gravity within the involved semicircular canal, under continuous nystagmus monitoring by video-Frenzel goggles.
Results: UBP starts with the evaluation of pseudo-spontaneous nystagmus in the primary gaze position and continues with the upright Head Pitch Test (uHPT) by forward and backward head bending along the pitch plane. The uHPT can indicate whether horizontal or vertical semicircular canal is involved. If horizontal canal is suspected, the upright Head Roll Test (uHRT) usually provides the diagnosis of the involved side and arm by tilting the patient's head rightward and leftward along the roll plane. Conversely, canalolithiasis involving the posterior semicircular canal can be diagnosed with the uHPT alone. Nevertheless, if necessary, the diagnostic sensitivity can be increased by head movements along the right anterior – left posterior (RALP) and left anterior – right posterior (LARP) canal planes (uRALP/uLARP test). Our multicenter experience is reported.
Conclusions: Following the UBP, most BPPV form can be diagnosed in upright position, allowing clinicians to proceed immediately with proper physical treatment and avoiding unpleasant maneuvers to patients.
Bascule maneuver along LARP/RALP planes in the management of atypical PC-BPPV variants and its role in localizing debris
Andrea Castellucci1, Pasquale Malara2, Salvatore Martellucci3, Paolo Russo1, Sara Donvito4, Angelo Ghidini1, Luigi Califano5, Giacinto Asprella Libonati6
1AUSL - IRCCS di Reggio Emilia, ENT Department, Reggio Emilia, Italy
2Centromedico, Audiology & Vestibology Service, Bellinzona, Switzerland
3AUSL di Latina, ENT Department, Latina, Italy
4University Hospital of Modena, ENT Department, Modena, Italy
5San Pio Hospital, Department of Audiology and Phoniatrics, Benevento, Italy
6Giovanni Paolo II Hospital, Vestibology & ENT Unit, Policoro, Matera, Italy
Purpose: While typical posterior canal (PC)-BPPV is successfully managed with standard repositionings, atypical variants, where otoconia settle in uncommon/stenotic canal tracts generating unusual positional nystagmus, are usually refractory and their management is still debated. They include PC-cupulolithiasis, apogeotropic PC-BPPV, sitting-up vertigo and PC-canalith jam. Impulsive maneuvers might be beneficial. While Brandt-Daroff exercises aim to disperse debris using random rotations, we designed a tailored impulsive maneuver along the affected canal plane (LARP or RALP), aiming to treat these variants or to convert them in typical forms, thus allowing to localize otoconia in uncertain cases.
Methods: Once placed the patient in the 1st(45°-face-up on the affected side) and then in the 2ndSemont position (45°-face-down on the healthy side), he is then briskly and repeatedly “basculed” side-to-side in a pendular fashion (up-to 5 times per session) with the same head direction (along the LARP or RALP plane) until variation or receding of positional nystagmus.
127 patients (33 males, 94 females, mean age 61.9±12.4 years) with atypical PC-BPPV or anterior canal (AC)-BPPV were prospectively “basculed” along the LARP (75 cases) and RALP (52 cases) planes. 42 subjects had PC-cupulolithiasis, 35 apogeotropic PC-BPPV, 35 sitting-up vertigo, 9 refractory PC-BPPV, 3 canalith jam and 3 AC-BPPV.
Results: BPPV directly resolved in 44 cases, while it converted into a typical variant in 63 cases (PC-BPPV in 38, lateral canal-BPPV in 22, AC-BPPV in 3) either in the same session or in the following evaluations, thus allowing to detect the original otolith position in most PC-cupulolithiasis and sitting-up variants (utricular side in 44 cases, long-arm side in 27 cases). In 85% of the remaining uneventful 20 cases, a coexistent ipsilesional vestibular migraine/Meniere’s disease was detected, revealing a possible buoyancy mechanism mimicking atypical PC-BPPV.
Conclusions: From our preliminary data, the “bascule maneuver” seems to represent a promising management for atypical PC-BPPV.
Benign positional paroxysmal vertigo and its relation with gravity and canal jamming
Haider Alsarhan
1
1College of medicine / mustansiriyah University – IRAQ
Purpose: is understanding of the nystagmus pattern induced by the presence of otoconias in a specified semi-circular canal.
Methods: otoconias when freely moving in the lumen of the semi-circular canal usually induced by the gravitational force produced by a head movement which will lead to movement of the otoconias to the most dependent part of the canal; This can be highly affected and interrupted by the presence of canal jam that interferes with the normal gravitational flow of these otoconias; the presence of canal jam should be documented by specific findings in the vestibular tests battery otherwise the diagnosis of BPPV is highly questionable and other causes of positional vertigo should be assessed and accordingly nystagmus induced should not be considered as otoconia-related nystagmus and other forms should be looked for like migrainous positional nystagmus or central positional nystagmus.
Results: Results of video-oculo-graphy recordings along with other vestibular testing results for more than 8 patients will be demonstrated according to the time slot allowed by the organizers.
Conclusions: understanding these 2 factors in testing the nystagmus pattern can significantly increase the accuracy of the diagnosis of the different conditions that cause nystagmus induced by positioning tests.
Bilateral Lateral Canal BPPV - Tips for Diagnosis
Sandeep Kumar1, Srinivas Dorasala2, Preeti Madaan3
1Bharti ENT & Vertigo Clinic
2Jawahar Lal Nehru Medical College, Belgavi, Karnataka, India
3North York General Hospital, Toronto, Canada
Purpose: To determine factors and observations that can be of help in the diagnosis and management of this unusual variety of BPPV, where both lateral canals are involved.
Methods: Retrospective study of 5 patients of bilateral lateral canal BPPV - their presentation, results of positional tests, videonystagmographic findings, and their management by particle repositioning maneuvers as well as their outcome.
Results: Data from 5 patients presenting with a history of positional vertigo was analyzed. All had an inversion of initial geotropic nystagmus to apogeotropic nystagmus mostly during diagnostic positional testing. Secondary signs of lateralization, like the bow lean test & sit to supine test were found extremely helpful in reaching a final diagnosis of co-existent canalo and cupulolithiasis. All patients were managed successfully with particle repositioning maneuvers.
Conclusions: The involvement of both lateral canals is extremely challenging to diagnose. It is highly recommended to take the help of accessory tests like bow lean or sit-to-supine tests. In cases of positional vertigo having inversion of geotropic nystagmus in the supine roll test, involvement of both lateral canals should be actively sought.
Characteristics of nystagmus and lateralization of the horizontal semicircular canal light cupula
Wenjing Qin1, Liying Chang1, Zheng Liu1, Yi Fang1, Yanhan Zhu1
1Department of Neurology, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science.
Purpose: To investigate the characteristics of nystagmus and lateralization of light cupula.
Methods: Eighty-five patients with light cupula were reviewed. We summarized the characteristics of spontaneous nystagmus, supine positioning nystagmus, bow nystagmus, and lean nystagmus. Then, the side of the NP was identified as the affected side, and the values of the fast phase direction of spontaneous nystagmus, supine positioning nystagmus, bow nystagmus, and lean nystagmus, as well as the intensity of the DCPN in the SRT, were used to diagnose the affected sides. Caloric testing was also performed for some patients.
Results: The frequencies of supine positioning nystagmus, bow nystagmus, and lean nystagmus were higher than spontaneous nystagmus (p<0.001). The second NP and third NP were readily detected. Lateralization through the fast phase directions of bow and lean nystagmus did not significantly differ from that of NP (all p>0.05). However, the accuracy rate of lateralization through the sides with more vigorous DCPN in the SRT was 63.5%, significantly lower than through NP (p<0.001). Particularly in patients with supine positioning nystagmus, the rate was only 58.7% (p<0.001) compared with 100% in patients without SPN(n=10). Among the 70 patients who underwent caloric testing, 37 had abnormal CP.
Conclusions: Besides utilizing the NP to determine the affected side, the fast phase direction of the bow nystagmus or lean nystagmus can also aid in identification. However, a simple comparison of the intensity of DCPN in SRT cannot provide accurate lateralization. There is a high incidence of CP on the affected side of light cupula.
Clinical characteristics difference between patients with horizontal semicircular canal light cupula and heavy cupul
Liying Chang1, Xueyan Zhang1, Jiao Xu1, Mei Hu1
1Department of Neurology, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science.
Purpose: This study explored the difference in clinical characteristics between patients with the horizontal semicircular canal light cupula (HSC-Lcu) and horizontal semicircular canal heavy cupula (HSC-Hcu).
Methods: In this retrospective study, we included 52 patients with HSC-Lcu (17 males, mean age 66.6 years) and 48 patients with HSC-Hcu (22 males, mean age 67.7 years). We compared the nystagmus characteristics, canal paresis (CP), and laboratory results associated with atherosclerosis and plasma protein and sodium levels between the two groups.
Results: The history of sudden sensorineural hearing loss (SSNHL) was more common in HSC-Lcu (n=8) than HSC-Hcu (n=0) (p=0.006). In the supine roll test (SRT), the maximum slow-phase velocity (SPV) of the affected side (median 12.0 deg/s) was higher than the unaffected side (median 9.5 deg/s) in HSC-Lcu (p=0.047), and no significant difference in HSC-Hcu (p=0.863). However, the maximum SPV of the affected side was no higher than the unaffected side in 13 patients with HSC-Lcu. CP in the HSC-Lcu (n=30) was higher than HSC-Hcu (n=16) (p=0.008). The supine position nystagmus (SPN), the three null points (NP), and the laboratory results showed no significant difference between the two groups.
Conclusions: HSC-Lcu and HSC-Hcu were more prevalent in females than males. The patient with SSNHL was more vulnerable to HSC-Lcu than HSC-Hcu. Determining the affected side of HSC-Lcu and HSC-Hcu through nystagmus intensity in the SRT was inconsistent with the result from NP. CP was more general in HSC-Lcu than in HSC-Hcu. The pathophysiology of HSC-Lcu and HSC-Hcu remains to be elucidated.
Clinical Characteristics of Post-Traumatic BPPV: A Comparative Study with Idiopathic BPPV
Tae Hoon Kong1, Gi-Sung Nam2, Dae Bo Shim3
1Department of Otorhinolaryngology - Head and Neck Surgery, Yonsei University Wonju College of Medicine, Wonju, Korea
2Department of Otorhinolaryngology - Head and Neck Surgery, Chosun University College of Medicine, Gwang-ju, Korea
3Department of Otorhinolaryngology, Hanyang University College of Medicine, Myonji Hospital, Goyang, Korea
Purpose: This study aims to compare the clinical and demographic characteristics of post-traumatic benign paroxysmal positional vertigo (BPPV) with idiopathic BPPV, emphasizing the impact of trauma severity on post-traumatic BPPV's clinical features.
Methods: A retrospective analysis was conducted on 66 patients diagnosed with post-traumatic BPPV at a Regional Trauma Center from January 2016 to June 2023, and 105 patients diagnosed with idiopathic BPPV from January 2022 to June 2023. Post-traumatic BPPV was defined as BPPV diagnosed within 30 days post-trauma. The diagnosis of BPPV, based on the Bárány Society's criteria, included the canalolithiasis type of Posterior Canal BPPV, both the canalolithiasis and cupulolithiasis types of Horizontal Canal BPPV, Anterior Canal BPPV, and multi-canal BPPV. The study assessed BPPV subtypes, the number of canalith repositioning maneuvers (CRM) needed for resolution, time to referral, recurrence rates, and trauma-related hospitalization periods.
Results: The post-traumatic BPPV group was significantly younger (58.0±15.2 vs. 63.0±13.1 years, p=0.024) with an equal gender distribution and predominantly exhibited canalolithiasis types (90.9% vs. 66.7%, p<0.001). More CRMs were required for resolution in the post-traumatic group (2.0±1.3 vs. 1.3±1.1, p=0.001), though recurrence rates did not differ significantly between groups (6.1% vs. 8.6%, p=0.546). Diagnosis time post-major trauma was longer compared to minor trauma cases (19.6±19.0 vs. 4.8±2.2 days, p=0.002).
Conclusions: Post-traumatic BPPV differs from idiopathic BPPV in onset age, gender distribution, and the predominance of canalolithiasis BPPV types, requiring more CRMs for resolution. However, the recurrence rates are similar across both groups. The clinical manifestation of post-traumatic BPPV does not vary significantly with trauma severity, highlighting the necessity for early BPPV assessment following trauma, regardless of its severity. This study underlines the need for tailored management strategies for post-traumatic BPPV, focusing on its distinct characteristics and the importance of early diagnosis and treatment, especially after major traumas.
Comparison of the efficacy of the Epley maneuver and repeated Dix-Hallpike tests: A multicenter randomized study
Takao Imai1, Hidenori Inohara2
1Department of Otorhinolaryngology – Head and Neck Surgery, Bell Land General Hospital, Osaka, Japan
2Department of Otorhinolaryngology – Head and Neck Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
Purpose: Patients with benign paroxysmal positional vertigo of the posterior canal (pc-BPPV) exhibit BPPV fatigue, where the positional nystagmus diminishes with the repeated performance of the Dix-Hallpike test (DHt). BPPV fatigue is thought to be caused by the disintegration of lumps of otoconial debris into smaller parts and can eliminate positional nystagmus within a few minutes [similar to the immediate effect of the Epley maneuver (EM)]. In this study, we aimed to show the non-inferiority of the repeated DHt to the EM for eliminating positional nystagmus after 1 week.
Methods: Patients who had pc-BPPV were recruited and randomly allocated to Group A or Group B. Patients in Group A were treated using the EM, and patients in Group B were treated using repeated DHt. For both groups, head movements were repeated until the positional nystagmus had been eliminated (a maximum of three repetitions). After 1 week, the patients were examined to determine whether the positional nystagmus was still present. The groups were compared in terms of the percentage of patients whose positional nystagmus had been eliminated, with the non-inferiority margin set at 15%.
Results: Data for a total of 180 patients were analyzed (90 patients per group). Positional nystagmus had been eliminated in 50.0% of the patients in Group A compared with 47.8% in Group B. The upper limit of the 95% confidence interval for the difference was 14.5%, which was lower than the non-inferiority margin.
Conclusions: This study showed the non-inferiority of repeated DHt to the EM for eliminating positional nystagmus after 1 week in patients with pc-BPPV and that even the disintegration of otoconial debris alone has a therapeutic effect for pc-BPPV. Disintegrated otoconial debris disappears from the posterior canal because it can be dissolved in the endolymph or returned to the vestibule via activities of daily living.
Diagnostic efficacy of body roll test for lateral canal BPPV: A randomized controlled study
Eun-Ju Jeon1, Hyun Jin Lee1, Jae-Hyun Seo2, Yun-Jung Yang3
1Incheon St. Mary's Hospital, The Catholic University of Korea, Department of Otorhinolaryngology-Head and Neck Surgery, Republic of Korea
2Seoul St. Mary's Hospital, The Catholic University of Korea, Department of Otorhinolaryngology-Head and Neck Surgery, Republic of Korea
3College of Medicine, Catholic Kwandong University, Department of Convergence science, Republic of Korea
Purpose: The diagnosis of Lateral semicircular canal Benign Paroxysmal Positional Vertigo (LC-BPPV) utilizes the supine head roll test (HRT), which elicits nystagmus through bilateral head rotations in the supine position. Accurately identifying the affected side is vital, and assessed by compairing the intensity and duration of nystagmus across both sides. Factors such as cervical spine pathology, advanced age, or obesity can impair neck mobility, potentially compromising HRT's diagnostic precision. The Body Roll Test (BRT) provides an alternative, administering a symmetrical and faster rotational stimulus which may enhance lesion side determination. This study aims to evaluate the diagnostic efficacy of BRT against HRT in determining the affected side in patients with LC-BPPV.
Methods: Forty-three patients manifesting symptoms of LC-BPPV were randomized into two groups. Group A (n=21) underwent HRT followed by BRT after a five-minute interval, while Group B (n=22) received these tests in reverse sequence. The tests were conducted using video-Frenzel goggles and the characteristics of nystagmus were assessed.
Results: The mean age was 52 years, with a nystagmus type distribution of 18 geotropic to 25 apogeotropic. There was no significant difference in the diagnostic rates of lesion-side between the first (72.0%, 31/43) and second (74.4%, 32/11) test. Although BRT had a higher rate of lesion-side diagnosis at 79.1% (34/43) compared to HRT at 67.4% (29/43), the difference was not statistically significant (P>0.05). There was no significant difference in postural discomfort and pain score between the groups.
Conclusions: Both BRT and HRT demonstrated comparable efficacy in diagnosing the affected side in LC-BPPV patients. Although BRT did not show significant superiority over HRT, it may serve as a viable alternative for patients with limited neck mobility. Further research with an expanded sample size is warranted to conclusively assess the potential diagnostic benefits of BRT over HRT.
Effect of jump before and after epley maneuver
Pradeep Vundavalli1, Srinivas Dorasala2
1Asian ENT Hospital, Visakhapatnam, India
2Annayya Hospital, Bengaluru, India
Purpose: To study the effect of jump ( up and down ) in the efficacy of diagnosis and managemnet of posterior canal BPPV. Abrupt jumping can cause loosening of otoconia in the semicircular canal before the performance of maneuver and also jumping up and down post maneuver helps the otoconia to settle down into utricle
Methods: 380 patients diagnosed of posterior canal bppv in two tertiary neurotology centres were included in the study. 200 patients were included in group A and 180 patients in group B. All the patients in group A were instructed to perform 5 jumps ( Up and Down ) before the epley maneuver and after the maneuver. This was compared with the control group were only epley was done without any jump.
Results: While performing Epley in the subjects, Jumping up and down pre and post maneuver had the highest rate of elicitation of nystagmus during the maneuver and reduced rate of recurrence of posterior canal BPPV. When compared with the second group, the first group ( Jumping group ) had lower recurrence/ residual disease with a higher rate of successful maneuver.
Conclusions: Instructing the patient and assisting them to make 5 jumps before and after Epley maneuver had given a higher success rate for the repositioning of the particles in posterior canal BPPV. Jumping before the maneuver can liberate jammed/ occluded / free otoconia in the semicircular canal arm making them susceptible for the movement during the maneuver. Jumping after the maneuver helps the otoconia to be liberated into the utricle from the common crus more efficiently thereby reducing residual/ recurrent posterior canal BPPV.
Efficacy of automated repositioning chair in comparison with bedside canalith repositioning manoeuvre on managing BPPV
Shankai Yin
1
1Shanghai Sixth People's Hospital
Purpose: Manual canalith repositioning manoeuvre (Bedside-CRM) and software-controlled benign paroxysmal positional vertigo (BPPV) repositioning chair (Chair-CRM) are used to treat BPPV, but their comparative efficacy remains unclear due to the lack of randomized controlled clinical trials.
Methods: In this prospective, multicentre, open-label, stratified blocked randomized, parallel group clinical trial, patients with unilateral BPPV were randomly assigned to Chair-CRM or Bedside-CRM in 1:1 ratio. Efficacy was evaluated immediately after the first treatment and then weekly for 4 weeks. The primary outcome was the response (cured and improved) rate at 1-week post intervention. The secondary outcomes were response and curative rates at weekly follow-up for 4 weeks. Analysis was applied in full analysis set (FAS) and per-protocol set (PPS). Missing efficacy data were imputed using the last observation carried forward method.
Results: 404 participants were recruited. Response rate was significantly higher in Chair-CRM group than in Bedside-CRM group (97.51% vs 86.70%, P<0.001) at 1-week post treatment. The sustained response rate till 2-week follow-up was significantly higher in Chair-CRM group than in Bedside-CRM group. Generalized estimating equation analysis showed that response and curative rates were significantly higher in the Chair-CRM group than in the Beside-CRM group (response rate, OR=6.13, 95%CI=3.16-11.82, P<0.001; curative rate, OR=1.44, 95%CI=1.06-1.95, P=0.018). Adverse events rate was similar between the two groups. Both strategies achieved satisfactory effects at 4 weeks post treatment.
Conclusions: Chair-CRM results in superior therapeutic effect than Bedside-CRM by achieving rapid symptom relief and sustained resolution for BPPV patients.
From Diagnosis to Therapy Following Nystagmus Suggestions: BPPV therapy according to the “Minimum Stimulus Strategy”
Andrea Castellucci1, Fernanda Asprella Libonati2, Giacinto Asprella Libonati3
1ENT Unit, Department of Surgery, Azienda USL—IRCCS di Reggio Emilia, Reggio Emilia, Italy
2Indipendent Researcher Rome Italy
3Giovanni Paolo II Hospital Policoro MT Italy
Purpose: The aim of this work is to show how to treat BPPV according to a minimally invasive approach, based on real-time monitoring of nystagmus during each step of the rehabilitation maneuvers.
This is the guided nystagmus approach of the “minimum stimulus strategy” (MSS).
Methods: Minimum Stimulus Strategy allows a step-by-step therapeutic approach to BPPV.
Monitoring nystagmus in real time allows us to understand where the canaliths are and in which direction they are moving.
We can read positive and negative prognostic signs by performing the maneuvers for the BPPV therapy of each semicircular canal.
In so doing we can modify our therapeutic strategy, adapting it to each patient.
Results: explanatory clinical cases with videos are reported, and the results of a multicenter experience which show how a nystagmus-guided approach leads to the resolution of symptoms in a large percentage of patients in the first session, minimizing the discomfort due to the autonomic reaction.
Conclusions: BPPV therapy is essentially a physical therapy, based on the so-called liberatory maneuvers, that is, movements that the therapist makes the patient perform in order to move the canaliths out of the affected semicircular canal.
Unfortunately, the maneuvers cause dizziness and sometimes intense associated neurovegetative effects. This is why we adopt a minimally invasive approach to BPPV, which is known as the “Minimum Stimulus Strategy.” Basically, this is a nystagmus-based strategy, usable in both the diagnostic and therapeutic approaches.
Our experience shows how the treatment of BPPV with MSS leads to excellent results especially in patients who arrive after a short delay from the onset of symptoms.
Is liberatory nystagmus in BPPV a marker of treatment success?
Patricia Castro1, Harry Akram2, Florencia Lerchundi3, Liliana Roman4, Hayo Breinbauer5, Diego Kaski6
11) Adult Diagnostic Audiology department, University College London Hospitals trust, UK. 2) Universidad del Desarrollo, Escuela de Fonoaudiologia, Facultad de Medicina Clinica Alemana, Chile
2Adult Diagnostic Audiology department, University College London Hospitals trust, UK
3Neurotology Department, Neurology Unit, FLENI, Buenos Aires, Argentina
4Department of Otolaryngology, Facultad de Medicina Clínica Alemana, Universidad del Desarrollo, Chile
51) Department of Otolaryngology, Facultad de Medicina Clínica Alemana, Universidad del Desarrollo, Chile. 2) Laboratory for Clinical Neuro-Otology and Balance-Neuroscience, Universidad de Chile, Chile
66) SENSE research unit, Department of clinical and movement neuroscience, Institute of Neurology, University College London, UK
Purpose: Benign Paroxysmal Positional Vertigo (BPPV) is the most common adult vestibular disorder worldwide. Its treatment reflects our current understanding of the underlying pathophysiology, namely free-floating otolithic debris within the semicircular canal, or adhered to the cupula. Repositioning manoeuvres, such as the Epley and Semont manoeuvres are highly effective. However, there remains a percentage of patients in whom such treatments are not successful despite being conducted appropriately. Unfortunately, there are no current indicators of effectiveness to help identify those patients who may need multiple manoeuvres or a different management for their positional symptoms. A clinical finding is the “liberatory” nystagmus; the eye movement at the end of the repositioning manoeuvres that are thought to represent the migration of the otolithic debris away from the canal. The relevance of these eye movements as a possible marker of treatment success is unknown.
Methods: Accordingly, in this study, we review 100 patients diagnosed with BPPV who underwent assessment and treatment for BPPV using oculography to identify the presence and duration of nystagmus at the end of the manoeuvre. We also follow them later to document if there was resolution after the manoeuvre or if they needed further sessions.
Results: Interim analysis shows that a shorter latency and longer duration of nystagmus at diagnosis are related to the appearance of nystagmus after the manoeuvre (p < 0.01). However, this nystagmus did not seem to be related to the improvement or resolution of BPPV after the manoeuvre.
Conclusions: The presence of nystagmus at the end of repositioning manoeuvres in BPPV may indeed represent movement of the otolithic debris towards the common cross but does not necessarily constitute a marker of treatment success. Data is still being collected and a more robust analysis will be presented henceforth.
Persistent variant av Apogeotropc direction changing positional nystagmus
Tatjana Tomanovic
1
11. Department of ENT-Hearing and Balance, Karolinska University Hospital, Huddinge, Stockholm, Sweden. 2. Department ENT, Karolinska Institutet, CLINTEC, Stockholm, Sweden
Purpose: Apogeotropic positional direction-changing nystagmus (A-PDCN) refers to horizontal nystagmus that alters direction when the head is turned sideways while in a supine position. The most likely cause is cupulolithiasis; however, certain variants of this condition may show limited improvement with repositioning maneuvers.The aim of this observational study was analyzing the vestibular symptoms and vestibular laboratory tests patients with A-PDCN. The included patients were followed up with ta same test battery after few years. Evaluation of symptom severity was assessed at follow up with two self-reported scales: Dizziness Handicap Inventory and Vertigo Symptom Scale.
Methods: The 26 patients were initially recorded upon inclusion and then again during a follow-up period, with a minimum time difference of one year between the recordings. Examination included quantification of nystagmus in different head positions with caloric test, VEMP-s, SVH but also we analyzed data from patients' journals focusing on the symptoms of positional vertigo.
Results: We enrolled 26 patients (14 women) with M= 65 years (42–80 years), with A-PCDN, all of whom had a history of recurrent P-BPPV. During follow-up, A-PDCN was observed in the majority of patients (65%). Patients evaluated with subjective visual vertical exhibited the highest rate of abnormal test results, both initially (61%) and at follow-up (65%). We also found that none of the signs in vestibular testing or nystagmus direction reliably identified the affected side. According to self-reported scales, most patients experienced headaches and brief episodes of dizziness and confusion in VSS. In the DHI, respondents commonly reported disturbance with rapid head movements and frustration due to these symptoms.
Conclusions: Patients with recurrent BPPV develop persistent apogeotropic positional nystagmus over time. Pathological results in vestibular test battery shows minor change over the years. They experience constant unsteadiness worsened by head movements, leading to significant frustration.
Personalizing the Epley Maneuver through Computational Modeling of Vestibular Anatomy
Ismael Arán-Tapia1, Andrés Soto-Varela2, Vicente Pérez-Muñuzuri1, Sofía Santos-Pérez2, Ismael Arán3, Alberto P. Muñuzuri1
1University of Santiago de Compostela, Group of Non Linear Physics, Spain
2Complexo Hospitalario Universitario of Santiago de Compostela, Department of Otorhinolaryngology, Spain
3Complexo Hospitalario Universitario de Pontevedra, Department of Otorhinolaryngology, Spain
Purpose: Our study delves into the efficacy of the Epley maneuver for benign paroxysmal positional vertigo (BPPV), exploring whether treatment outcomes can be optimized through personalized approaches based on individual anatomical variations.
Methods: Employing high-resolution micro computed tomography imaging of the human membranous labyrinth, we designed a mathematical model utilizing computer fluid dynamics and Lagrangian particle modeling. This model simulated the dynamics of endolymphatic fluid and otoconia throughout all the steps of the Epley maneuver.
Results: Our simulations revealed shortcomings in the standard application of the Epley maneuver, particularly in ensuring otoconia reach the final desired position within the utricular macula. Notably, steps 3, 4, and 5 exhibited increased susceptibility to treatment failure. Personalizing the maneuver based on variations in rotation angles showed promise in preventing unintended displacement into critical regions. Additionally, smaller otoconia required longer intervals between maneuver steps compared to the time standards employed today.
Conclusions: Our study underscores the potential to enhance the effectiveness of the Epley maneuver in treating BPPV through numerical simulations. These findings emphasize the importance of personalized treatment maneuvers that consider individual anatomical variations, thereby paving the way for personalized medicine in vestibular clinical practice.
Prevention of Recurrent BPPV: The Role of Combined Supplementation with Vitamin D and Antioxidants
Rudi Pecci1, Fernanda Asprella Libonati2, Giacinto Asprella Libonati3
1Audiology Clinic, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
2Indipendent Researcher Rome Italy
3Giovanni Paolo II Hospital Italy
Purpose: Benign paroxysmal positional vertigo (BPPV) usually has a favorable course, although it is possible to observe BPPV with a high recurrence rate. Previous studies suggested that vitamin D deficiency might affect BPPV recurrences, and oxidative stress might play a complementary role in BPPV pathogenesis.
Methods: This multicentric trial aimed to evaluate the effectiveness of oral nutritional supplementation with a compound of alpha-lipoic acid, Carnosine, and Zinc (LICA® (Difass International, Coriano (RN), Italy)), vitamins of group B and vitamin D in preventing BPPV recurrences.
A total of 128 patients with high recurrence-BPPV were randomized in three arms: Arm 1 consisted of subjects with “insufficient” or “deficient” vitamin D blood levels, treated with daily oral supplementation of alpha-lipoic acid, Carnosine, and Zinc vitamins of group B and vitamin D3 (800 UI), Arm 2 included BPPV subjects with “sufficient” vitamin D who did not receive any nutritional support. Arm 3 included subjects with a “sufficient” serum concentration of vitamin D who received supplementation with a compound of alpha-lipoic acid, Carnosine, and Zinc and Curcumin.
Results: After six months of follow-up, a significant reduction of BPPV relapses compared to the baseline was found only in Arm 1 (−2.32, 95% CI: 3.41–1.62, p-value < 0.0001).
Conclusions: Patients with frequent relapses of BPPV should be considered at high risk for hypovitaminosis D and routinely screened for this condition following appropriate therapy with repositioning maneuvers.
This study suggested that oral nutritional supplementation with a compound of vitamin D3, ALA, Carnosine, and Zinc, vitamins of group B, can prevent relapses and reduce symptoms related to high-recurrence BPPV in patients showing insufficient or deficient serum concentration of 25 (OH) D.
The administration of vitamin D in association with a powerful antioxidant enhances its effects resulting in reducing the risk of developing new episodes of BPPV and improving its clinical course after maneuvers.
Proposal of a Standardized Testing Protocol for BPPV : Using 3D Simulations for Insights into Otolith Movement
Anita Bhandari1, Rajneesh Bhandari1, Herman Kingma2, David Zee3, Raymond van de Berg2, Danielle Nuti4
1NeuroEquilibrium, India
2Maastrich University, Netherlands
3John Hopkins Medical College, USA
4Sienna University,Italy
Purpose: Background - Benign Paroxysmal Positional Vertigo (BPPV) is a common vestibular disorder caused by displaced calcium carbonate crystals in the inner ear. This study explored if and how the sequence of performing the different diagnostic positional maneuvers effecs the outcome of each manoever. Otolith debris movement and nystagmus patterns in BPPV of the canalithiasis type were studied using 3D simulations.
Methods: 3D Simulations of Supine Roll Test, Dix-Hallpike maneuver and Deep head hanging test were used to study various types of horizontal, posterior and anterior canal BPPV. The simulations allowed visualization of the otolith debris movement. The results of sequence of tests and starting side of the tests (from left or right) were observed.
Results: Simulations of horizontal canal BPPV showed different patterns of nystagmus such as direction changing, direction fixed and unilateral nystagmus on Supine Roll Test (SRT), depending on position of the debris within the horizontal canal and the side to which the test was started. Simulations of the Dix-Hallpike maneuver showed that this test procedure can displace debris in the horizontal canal and affect the outcome of the SRT when done afterwards. The SRT had little or no impact on debris movement in the vertical canals. The deep head hanging test can displace debris in the posterior and horizontal canal.
Conclusions: An order effect can occur when performing diagnostic maneuvers for BPPV. The maneuvers can displace debris in the semicircular canals into new positions, that may influence the findings in subsequent maneuvers. This could confound the interpretation of diagnostic test results. A standardized testing protocol, as proposed in this article, can decrease the order effect and might facilitate better interpretation of test results, a higher diagnostic accuracy, and improve outcomes in BPPV management.
Quantified Assessment of 3D Nystagmus Patterns in Suspected BPPV Patients
Kamran Barin1, Michelle Petrak2, Amy Cassidy3, Susan Whitney4
1The Ohio State University, Department of Otolaryngology Head & Neck Surgery, USA
2Interacoustics, Denmark
3University of Pittsburgh School of Health and Rehabilitation Sciences, USA
4University of Pittsburgh Medical Center, Departments of Physical Therapy and Otolaryngology, USA
Purpose: Patients with posterior canal benign paroxysmal positional vertigo (BPPV) have a characteristic response of torsional-vertical nystagmus after a Dix-Hallpike maneuver. The nystagmus usually has a delayed onset with the intensity increasing rapidly and then subsiding over a relatively short duration of less than one minute. The purpose of this pilot study was to quantify and assess three-dimensional eye movements in patients with BPPV.
Methods: Horizontal, vertical, and torsional eye movements were recorded with a VNG system in 15 patients with case histories consistent with BPPV. The nystagmus response patterns were quantified by the latency, peak nystagmus intensity, duration, rise time, and fall time parameters.
Results: The results showed a high degree of variability in the response parameters, which signifies that a typical response pattern is not universal in patients with BPPV. In addition to the torsional-vertical nystagmus response, all patients exhibited different levels of horizontal nystagmus. However, the direction and the timing of the responses were not consistent. Some patients showed 3D nystagmus patterns that lasted much longer than the typical BPPV responses. Other patients had low levels of nystagmus in response to the Dix-Hallpike maneuver contralateral to the affected side.
Conclusions: The differences in response patterns may signify differences in the composition or the placement of otoconia within the canal, which may affect the patient symptoms and the outcome of the repositioning maneuvers. In addition, this pilot study demonstrates the need for standardization of nystagmus recording protocols as responses to the Dix-Hallpike maneuver are usually disconjugate. The ratio of torsional to vertical nystagmus intensities depends: 1) on the gaze direction and 2) on whether the measurements are made from the ipsilateral or contralateral eye.
Relationship between Nystagmus characteristics and Maneuver efficacy for LSC BPPV: a prospective study
Pedro Branco1, Catarina Pimentel Morais1, Luís Castelhano1, Filipe Correia1, Sílvia Pereira1, Pedro Escada1
1Hospital Egas Moniz - CHLO, Portugal
Purpose: To investigate whether a specific nystagmus observed during Gufoni or Gufoni-Appiani maneuvers can predict its efficacy, eliminating the need for deferred diagnosis of a recalcitrant lateral semicircular canal (LSC) benign paroxysmal positional vertigo (BPPV).
Methods: Prospective cohort in a tertiary center. All patients diagnosed with LSC BPPV by McClure-Pagnini test and confirmed by Bow and Lean test, between October 2022 and March 2024, were includes and treated with the Gufoni (for the geotropic variant) or Gufoni-Appiani (for the apogeotropic variant) maneuvers. The presence and the characteristics of the nystagmus induced in the three intermediate positions of the maneuvers were recorded. Fifteen minutes after the therapeutic maneuver, all patients were reevaluated with the McClure-Pagnini test to determine the therapeutic success. A successful maneuver was defined as absence of vertigo and nystagmus with McClure-Pagnini maneuver after a therapeutic maneuver. Success rates of Gufoni and Gufoni-Appiani maneuvers were calculated. A statistical analysis was performed to relate nystagmus in the intermediate positions and the final result and to find clinical factors associated with no response.
Results: 29 patients (28,6% male) were included in the study, 17 (58,6%) with right-side LSC BPPV and 22 (75,9%) with a geotropic variant. Bow and lean test induced horizontal nystagmus in 25 patients (86,2%). The therapeutic success of Gufoni and Gufoni-Appiani maneuvers were 73,5% (N=25) and 70% (N=7), respectively. Male, tall and heavy patients had worse outcomes (p=0,005, p=0,013 and p=0,044, respectively). An apogeotropic nystagmus during Gufoni maneuver was associated with an unsuccessful result (p=0,031). The presence of an ampullipetal flow-induced nystagmus during both maneuvers had an accuracy of 77,3% in detecting a resistant BPPV.
Conclusions: The presence of an ampullipetal flow-induced nystagmus during Gufoni or Gufoni-Appiani maneuvers suggests an unsuccessful result. Its presence may exempt subsequent reevaluation, reducing waiting time for a second diagnostic maneuver.
Telemedicine: Agreement of BPPV diagnoses between in-person and video recordings of the same consultations
Ali Melliti1, Sophie Vanbelle2, Raymond van de Berg1
1Maastricht University Medical Center, Department of Otorhinolaryngology, The Netherlands
2Maastricht University, FHML Methodologie & Statistiek, The Netherlands
Purpose: This study aimed to assess the inter-methods agreement between traditional in-person consultations and eye movement recordings, in diagnosing BPPV during diagnostic maneuvers. This is a step toward the analysis of the feasibility, reliability and validity of telemedicine in diagnosing BPPV.
Methods: Two experts (Expert A and B) from a tertiary referral center screened 100 vestibular patients for BPPV using the TRV chair (Interacoustics, Middlefart, DK). Patient inclusion criteria comprised individuals aged at least 18 years-old. During these in-person consultations diagnostic maneuvers and eye movements were recorded. These video recordings comprised the patients' eye and body positions across Five different conditions: Sitting upright, supine position, supine roll left and right, Dix Hallpike left, and Dix Hallpike right. One month following the final data collection, each expert independently analyzed their own video recordings. They were asked to indicate the presence or absence of BPPV, and to specify the type in case of BPPV. Both participants were blinded to patient information and history during the analysis. Agreement between in-person consultations and eye movement recordings was calculated using Cohen’s Kappa and percentage of agreement.
Results: During the in-person consultations, Expert A diagnosed BPPV in 40% of the cases, and Expert B diagnosed BPPV in 19% of the cases. Expert A diagnosed 88% of patients with the same condition (BPPV present or absent) as in-person consultations (88% agreement; Cohen’s kappa of 0.75, [0.62,0.88]). Expert B diagnosed 89% of patients with consistent results (89% agreement; Cohen’s kappa of 0.62, [0.42,0.82]).
Conclusions: A high percentage of agreement is found when comparing in-person consultations with analysis of video recordings of the in-person consultations, regarding the presence or absence of . This shows the feasibility of using telemedicine to diagnose BPPV remotely. However, further studies are needed to assess the inter-rater reliability and validity in BPPV diagnosis in a telemedicine setting.
5. Bilateral Vestibulopathy
Assessing balance in patients with bilateral vestibulopathy with the Mini-Balance Evaluation Systems Test
Meichan Zhu1, Lisa van Stiphout1, Mustafa Karabulut1, Angélica Pérez Fornos2, Nils Guinand2, Kenneth Meijer3, Raymond van de Berg1, Christopher McCrum3
1Division of Balance Disorders, Department of Otorhinolaryngology and Head and Neck Surgery, School for Mental Health and Neuroscience, Maastricht University Medical Center, Maastricht, The Netherlands
2Service of Otorhinolaryngology and Head and Neck Surgery, Department of Clinical Neurosciences, Geneva University Hospitals, Geneva, Switzerland
3Department of Nutrition and Movement Sciences, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands.
Purpose: 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.
Conclusions: 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.
Atrophy of the hippocampus and postural control are linked in patients with idiopathic bilateral vestibulopathy
Olivier Etard1, Thomas Caille1, Olga Kuldavletova1, Mikaël Naveau2, Gaëlle Quarck1, Antoine Langeard1, Marion Hay1, Adela Kola1, Michel Toupet3, Christian Van Nechel3, Charlotte Hautefort3, Gilles Clément1, Pierre Denise1
1Normandie Université, UNICAEN, INSERM, COMETE, CYCERON, CHU Caen
2Normandie Université, UNICAEN, CNRS, INSERM, UAR3408 CYCERON, Caen, France
3Institut de Recherche en Oto-Neurologie, IRON, Paris, France
Purpose: The controversy surrounding the observed hippocampal atrophy after vestibular injury persists. This may be due to the heterogeneity and small sample size of patients in each study. In this study, we aim to address this issue by analyzing the largest and most homogeneous cohort of patients with idiopathic bilateral vestibulopathy (IBV).
Methods: Thirty patients with IBV and 30 age- and sex-matched controls were studied. Hippocampal subfields were evaluated using a 3T MRI scanner (GE PREMIER). We used ASHS software to segment the substructures from the brain scans. For each subject, segmentation was performed using the combination of a T1-weighted 3D-PRAGE scan (1 mm isotropic) and a T2-weighted 2D-FSE oblique coronal scan perpendicular to the main hippocampal axis (0.4 x 0.4 x 2.0 mm3). Postural control was assessed by having participants stand on a force platform (Synapsys®, 100 Hz) with their eyes open for 60 seconds. The usual posturography parameters were calculated (CoP-length, CoP-Velocity,CoP-Sd...).
Results: As expected, patients with IBV showed worse postural control performance than the control group. Additionally, IBV patients had smaller hippocampal volumes, particularly in the CA1 subfield, compared to controls. Moreover, the IBV group showed a correlation between hippocampal volume and postural performance parameters, while no such correlation was observed in the control group.
Conclusions: IBV patients, who do not perceive gravity via their vestibular system, show impaired postural performance and reduced hippocampal volumes compared to a paired control group. Reduced CA1 volumes found in IBV may be directly related to increased CoP length, underscoring the potential key role of this structure in postural control in the absence of a functioning vestibular system. We propose that the absence of vestibular information may be related to the decrease in hippocampal volume, which subsequently affects postural control.
Dimethyl sulfoxide: A novel cause of asymmetric bilateral vestibulopathy
Vincent Seet
1
1Sir Charles Gairdner Hospital, Perth, Australia
Purpose: Acute bilateral vestibulopathy is commonly the result of vestibulotoxic drugs such as aminoglycoside antibiotics and certain chemotherapeutic agents. We report dimethyl sulfoxide as a novel cause of acute bilateral asymmetric vestibulopathy.
Methods: We present a case of an otherwise well 68-year-old patient who underwent endovascular embolisation of a left sided Cognard Grade III dural arteriovenous fistula using a liquid embolic agent containing a mixture of 8% ethylene vinyl alcohol dissolved in dimethyl sulfoxide.
Results: Immediately post-procedure, the patient experienced severe vertigo associated with nausea, vomiting and inability to walk for 2 days followed by chronic imbalance. Acute stroke was excluded through magnetic resonance imaging and computed tomography angiogram. Vestibular testing showed bilateral vestibulopathy, with moderate to severe impairment of the left horizontal, posterior and anterior canals, and mild to moderate impairment of the right horizontal and posterior canals, and bilateral saccular dysfunction. Audiogram showed mild presbyacusis.
He has never had vertigo before. He did not have past history of migraine, connective tissue disorder, autoimmune disease, meningitis or antecedent viral illness. Medication chart review did not show exposure to known ototoxic drugs. He had left pulsatile tinnitus secondary to the dural arteriovenous fistula which resolved after the embolisation procedure. Comprehensive bloods for secondary causes of bilateral vestibulopathy were normal.
Conclusions: Dimethyl sulfoxide has been shown to be toxic to cochlear hair cells, astrocytes and other organs. The toxicity depends on the dose as well as rapidity of exposure. Dimethyl sulfoxide has high diffusibility and it is hypothesised that the asymmetric vestibulopathy is due to higher accumulation of toxic compound in the adjacent left ear. Recognition of this previously unknown risk could alter current guidelines regarding the dose and injection rate of dimethyl sulfoxide during endovascular embolisation procedures and prevent bilateral vestibulopathy.
EEG correlates of vestibular-mediated processing of self-motion in healthy and bilateral vestibular failure
Zaeem Hadi1, Keven Du1, Thariny Suresh1, Solomiia Bandrivska1, Barry M Seemungal1
1Centre for vestibular neurology, Department of Brain Sciences, Imperial College London, UK
Purpose: The human vestibular system is key for sensing translational and angular accelerations. Patients with brain disconnection syndromes often develop vestibular agnosia (VA) such that the perception of self-motion is attenuated even with normal peripheral vestibular signalling. However, there are no established electrophysiological markers of vestibular-mediated self-motion processing in humans.
Methods: Experiments were performed in a computerized rotating chair in the dark with subjects instructed to keep their head straight and eyes open. Earplugs were used to reduce any ambient auditory noise and proprioceptive feedback was reduced by covering participants’ chair contact with soft pillows. 8 healthy young participants were rotated in yaw-plane at constant accelerations of 0, 10, 30, 60, 90, 120, 150, 180 deg/s/s in two sets of experiments (7 blocks, 792 total trials) whereas bilateral vestibular failure (BVF) patients (n = 7) were rotated at accelerations of 30, 60, 90, 120, 150 deg/s/s (2 blocks, 240 total trials). A 32-channel wireless EEG amplifier was used to record EEG simultaneously with chair rotations. The chair was accelerated and decelerated over 2s (1s each phase) using a symmetric triangular waveform to minimize post-rotational effects.
Results: Theta-frequency suppression (3-8 Hz) is linked with the processing of self-motion whereas transient theta increases occurring at switch phases of stimulus represent a combination of somatosensory and surprise-related arousal. BVF show no vestibular mediated theta suppression and upscale their somatosensory mediated theta increase.
Conclusions: Theta frequency suppression is a marker of vestibular-mediated self-motion perception, which is completely absent in BVF patients.
Enhancing perceptual and postural function in bilateral vestibulopathy by low-intensity vestibular noise stimulation
Max Wuehr1, Andreas Zwergal1, Klaus Jahn1
1German Center for Vertigo and Balance Disorders, LMU Munich, Munich, Germany
Purpose: Bilateral vestibulopathy (BVP) results in chronic postural instability, increasing the risk of falls and diminishing patients’ quality of life. Current treatment options, primarily focused on physical therapy, offer limited compensation for lost vestibular function. In recent years, low-intensity noisy galvanic vestibular stimulation (nGVS) has emerged as a non-invasive therapeutic alternative. nGVS is presumed to utilize the phenomenon of stochastic resonance, wherein impaired sensory information transfer can be optimized in the presence of weak sensory noise interference, to enhance residual vestibular function. Here we outline available evidence for the therapeutic efficacy of nGVS in BVP patients.
Methods: A series of experimental studies compared the therapeutic effects of nGVS versus sham stimulation on various aspects of vestibular function in BVP patients. Vestibular perceptual function, vestibular sensorimotor reflexes, static postural control, and dynamic gait performance were evaluated using psychophysical experiments and instrumented assessment of stance and gait function.
Results: nGVS effectively normalized increased vestibular perceptual and vestibulospinal reflex thresholds in BVP patients. This normalization translated into clinically relevant improvements in both static postural control and dynamic gait performance. The effectiveness of nGVS was particularly notable in individuals with measurable residual vestibular function, with patients exhibiting higher vestibular impairment experiencing the greatest benefits. Short-term application of nGVS did not result in any adverse effects.
Conclusions: nGVS represents a promising non-invasive approach to address vestibular perceptual and sensorimotor impairments associated with BVP. Further research is needed to explore its long-term effects on daily mobility and fall prevention.
Multi-frequency VEMPs improve detection of present otolith responses in bilateral vestibulopathy
Floor Lucieer1, Marly van der Lubbe1, Lisa van Stiphout1, Miranda Janssen2, Vincent van Rompaey3, Elke Devocht1, Angelica Perez-Fornos4, Nils Guinand4, Raymond van de Berg1
1Maastricht University Medical Center, Department of Otorhinolaryngology and Head & Neck Surgery, The Netherlands
2Maastricht University, Department of Statistics, The Netherlands
3University Hospital Antwerp, Department of Otorhinolaryngology and Head & Neck Surgery, Belgium
4Geneva University Hospital, Department of Otorhinolaryngology and Head & Neck Surgery, Switzerland
Purpose: To investigate whether multi-frequency Vestibular Evoked Myogenic Potential (VEMP) testing at 500 Hz, 750 Hz, 1000 Hz and 2000 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 Hz, 750 Hz, 1000 Hz and 2000 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 fifteen percent more present VEMP responses were obtained with multifrequency testing, compared to only testing at 500 Hz. The 2000 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.
Conclusions: 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.
Subjective instability perception and stepping responses in Bilateral Vestibular Hypofunction
Patricia Castro1, Toby Ellmers2, Richard Ibitoye3, Diego Kaski4, Adolfo Bronstein2
11. Adult Diagnostic Audiology department, University College London Hospitals trust, UK. 2. Universidad del Desarrollo, Escuela de Fonoaudiologia, Facultad de Medicina Clinica Alemana, Chile
2Centre for Vestibular Neurology, Department of Brain Sciences, Imperial College London, UK
31. Centre for Vestibular Neurology, Department of Brain Sciences, Imperial College London, UK. 2. SENSE research unit, Institute of Neurology, University College London, UK
44. SENSE research unit, Department of clinical and movement neuroscience, Institute of Neurology, University College London, UK
Purpose: The relationship between how unsteady we are (objective instability) and how unsteady we feel (subjective instability) follows a fairly tight logarithmic function. However, perceived instability can be impacted by a range of processes e.g. it can increase by anxiety. Here, we explore the relationship between objective and subjective instability in patients with bilateral vestibular hypofunction (BVH) during a dynamic postural task.
Methods: Participants stood on a platform oscillating at different velocities. Objective sway (trunk sway path), subjective instability and anxiety ratings were obtained. Foot lifts were also measured to investigate if protective stepping responses are critically dependent on vestibular function.
Results: Patients with BVH showed larger sway path than controls (t: -2.153, p<0.05). Patients had a marginally steeper objective-subjective instability curve slope compared to controls (p=0.053). Sled velocity thresholds to generate a foot response were not different between BVH patients and controls (p=0.904). Moreover, this foot response generation threshold was not correlated with their objective-subjective instability slope (p=0.427).
Conclusions: BVH patients’ objective-subjective slope data indicates a marginally heightened perception of instability for the same degree of objective sway. Importantly, patients with BVH did not exhibit changes in step generation. Our results indicate that the construction of perceived instability, and the generation of protective steps in response to such instability, relies on a central representation of the centre of mass rather than on peripheral vestibular input.
Temporal perception and the interaction between time and space in individuals with bilateral vestibular loss
Deborah Cecilia Navarro Morales1, Olga Kuldavletova1, Gaëlle Quarck1, Pierre Denise1, Gilles Clément1
1UNICAEN-INSERM U1075 COMETE, Université de Caen Normandie, Esplanade de la Paix, 14000 Caen, France
Purpose: Time perception plays a crucial role in daily cognitive functioning, yet it remains relatively understudied in individuals with bilateral vestibular loss (BVL). Existing research, limited as it is, indicates that BVL patients exhibit similar distortions in time perception as astronauts when assessed through a 1-minute production protocol. Our objective was to investigate the impact of bilateral vestibular loss pathology on time perception and its interaction with spatial awareness.
Methods: Twenty-seven patients diagnosed with bilateral vestibular loss (BVL) according to the Barany criteria participated in this study, comprising 15 female subjects and 12 male subjects with an average age of 60.1 ± 12.7 years. Additionally, 27 control subjects, consisting of 15 female subjects and 12 male subjects with an average age of 60.4 ± 13 years, were included. The study comprised three experiments: (a) a series of time perception tests administered via a virtual reality headset, involving production and reproduction of durations under single- or dual-task conditions; (b) a space-time interaction test conducted on a rotatory chair, comparing the reproduction of duration task under static conditions with two rotating conditions; and (c) a visual space-time interaction test performed on a computer.
Results: During the production dual-task, BVL patients exhibited shorter durations compared to control subjects (p=0.027). Unlike control subjects (p=0.036), BVL patients did not display space-time interaction on the rotatory chair task (p=0.837). However, both BVL patients and control subjects demonstrated space-time interaction in the visual task (p=0.011), with no difference between them (p=0.146).
Conclusions: BVL patients perceive time to be slower when confronted with a dual task. Additionally, during actual movement (rotations), time integration in these patients likely involves distinct sensory inputs compared to control subjects, resulting in abnormal space-time interaction.
The association between peripheral vestibular function, balance, and cognition: From inner ear to the brain
Joyce Bosmans1, Hanne Gommeren2, Griet Mertens2, Patrick Cras2, Angelique Van Ombergen2, Peter zu Eulenburg3, Vincent Van Rompaey2
1Department of Brain and Cognition, Leuven Brain Institute, KU Leuven, Leuven, Belgium & Experimental Laboratory of Translational Neurosciences and Dento-Otolaryngology, Faculty of Medicine and Health Sciences, University of Antwerp, Belgium
2Experimental Laboratory of Translational Neurosciences and Dento-Otolaryngology, Faculty of Medicine and Health Sciences, University of Antwerp, Belgium
3German Center for Vertigo and Balance Disorders, University Hospital, Ludwig-Maximilians-University Munich, Munich, Germany
Purpose: Given the expected rise in dementia prevalence, early diagnosis and treatment of modifiable risk factors is vital. Recent evidence suggests that vestibular loss is associated with Alzheimer’s disease and may even contribute to its onset. To substantiate this vestibular loss hypothesis, the association between peripheral vestibular function, balance, and cognition is studied.
Methods: This abstract summarizes the PhD thesis of the first author, consisting of five published articles. As such, this abstract describes (1) functioning of the peripheral vestibular end-organ and balance in older adults with MCI and Alzheimer’s disease, (2) cognition in older adults with bilateral vestibulopathy, and (3) whole-brain and hippocampal brain morphology in older adults with bilateral vestibulopathy. These three objectives are met while taking hearing status into account.
Results: (1) The p13 latency, a measure of saccular vestibular end-organ function, was delayed in participants with Alzheimer’s disease. Other measures of the sacculus or semicircular canals did not differ due to cognitive impairment. Advancing degrees of cognitive impairment demonstrated reduced balance, resulting in an increased fall risk. (2) People with bilateral vestibulopathy demonstrated a general deficit in cognition compared to their peers, which was most pronounced in the immediate memory, visuospatial cognition, and attention subdomains. (3) No alterations in whole-brain or hippocampal volume were observed in participants with bilateral vestibulopathy.
Conclusions: Vestibular and balance deficits were observed in older adults with cognitive loss, and cognitive deficits were observed in older adults with vestibular loss. However, this vestibular loss hypothesis remained on a behavioral level as no alterations regarding brain morphology were observed.
There is not always fog: Bilateral Vestibulopathy revisited
Leonardo Manzari1, Marco Tramontano2
1MSA ENT ACADEMY Center, Cassino, Italy
2Department of Biomedical and Neuromotor Sciences (DIBINEM), Alma Mater University of Bologna, 40138 Bologna, Italy
Purpose: Bilateral Vestibulopathy (BVP) is one of the most challenging causes of vestibular syndrome and equilibrium disorder. Quantifying the vestibulo-ocular reflex (VOR) gain by the video Head Impulse Test (vHIT) and studying otolith functions using ocular and cervical vestibular-evoked myogenic potentials could give differentresults rather than provide useful information to diagnose BVP. This study aims to retrospectively evaluate the semicircular canals and otoliths function in a group of in a group of patients who fullfil three out four (A, B and D) diagnostic criteria established by the Barany Society to diagnose Bilateral Vestibulopathy.
Methods: Medical records of 78 patients diagnosed as having BVP who underwent vestibular assessments including horizontal and vertical semicircular canal function testing with vHIT, as well as ocular and cervical vestibular-evoked myogenic potential testing, were reviewed.
Results: Among 78 patients, 54 exhibited significant VOR gain alterations detected by vHIT, affecting at least one or multiple pairs of semicircular canals (SCCs), including both horizontal and posterior canals. Additionally, 14 patients showed normal VOR gain values across the six SCCs but significant alterations in both ocular vestibular-evoked myogenic potentials (oVEMPs) and cervical vestibular-evoked myogenic potentials (cVEMPs).
Conclusions: New variants of BVP must be taken into consideration. These variants could also shed new light on the etiology of this nosological entity.
6. Central Vestibular Disorders
A midbrain circuit controlling vergence eye movements in humans and primates
Maximilian U Friedrich1, Anja Horn-Bochtler2, Shawn Hiew3, Robert Peach3, Vallabh Das4, Johannes Hartig3, Hazem Eldebakey3, Konstantin Butenko1, Jens Volkmann3, Chi Wang Ip3, Daniel Zeller3, Barbara Kelly Changizi5, Marianne Dieterich6, David S Zee7, Martin Reich3, Andreas Zwergal6, Michael D Fox1
1Center for Brain Circuit Therapeutics, Brigham and Women's Hospital, Harvard Medical School, Boston, US
2Institute of Anatomy, Faculty of Medicine, Ludwig-Maximilians Universität Munich, Germany
3Department of Neurology, University Hospital Würzburg, Germany
4College of Optometry, University of Houston, Houston, US
5Department of Neurology, Brigham and Women's Hospital
6German Center for Vertigo and Balance Disorders, DSGZ, University Hospital, Ludwig-Maximilians University, Munich, Germany
7Departments of Neurology, Ophthalmology, Otolaryngology - Head and Neck Surgery, The Johns Hopkins University School of Medicine, Baltimore, USA
Purpose: The human ability to coordinate each eye’s fine movements is pivotal for depth perception, a process critically shaping visual navigation of frontal-eyed species in three-dimensional space. Depth perception critically relies on two interdependent mechanisms: a binocular motor mechanism called vergence, precisely aligning each eye’s fovea on a target in three-dimensional space, as well as a sensory-perceptual mechanism, transforming the resulting two-dimensional visual signals into a single three-dimensional visual percept. While cortical circuits have been found to subserve the sensory-perceptual component of depth perception, surprisingly little is known about the subcortical circuits governing vergence eye movements in humans.
Methods: Here, we leverage a deeply phenotyped cohort of 66 patients with dorsal midbrain syndrome, the most common lesion-induced vergence disorder in humans.
Results: Causal voxel- and network-level mapping of lesions and deep brain stimulation fields in humans converged with histological circuit mapping in primates, highlighting the nucleus of the posterior commissure (NPC) and its crossing white matter pathways through the posterior commissure. Leveraging visual perceptive machine learning, we find that vergence oscillations in patients and those induced by pharmacological lesions to the NPC region in non-human primates share characteristic kinematic features (2.13 ± 0.72Hz in humans, 2.2 ± 0.36Hz in monkeys, p= .99).
Conclusions: Collectively, our multifaceted, trans-species approach suggests that the NPC region and its commissural pathways subserve binocular control, a domain commonly affected by frequent neurological conditions such as strabismus, traumatic brain injury and Parkinson’s disease.
Acute imbalance syndrome (AIS) versus acute vestibular syndrome (AVS): differentiation matters
Ken Möhwald1, Hristo Hadhizolev1, Laurenz Eberle2, Patricia Jaufenthaler2, Michael Strupp1, Klaus Jahn2, Julian Conrad3, Andreas Zwergal1
1LMU University Hospital, German Center for Vertigo and Balance Disorders (DSGZ) & Department of Neurology, Munich, Germany
2LMU University Hospital, German Center for Vertigo and Balance Disorders (DSGZ), Munich, Germany
3University Hospital Mannheim, Department of Neurology, Mannheim, Germany
Purpose: Stroke is a major differential diagnosis in acute vertigo, dizziness or imbalance. Current diagnostic algorithms (e.g., HINTS) are optimized for presentations with spontaneous nystagmus (SPN) (acute vestibular syndrome, AVS). However, in recent studies a relevant proportion of acutely dizzy patients had no SPN, but rather postural/gait imbalance (acute imbalance syndrome, AIS). We aimed to outline the pathoanatomical differences of AIS vs. AVS and its clinical implications.
Methods: Seventy-five patients (66.7±12.6y) with acute vertigo, dizziness or imbalance due to an MRI-proven stroke underwent clinical and quantitative vestibular, ocular motor and postural testing (VOG/posturography). Patients were classified as suffering from AIS or AVS based on the presence of SPN. Stroke lesion distribution was depicted and supplemented by structural disconnectome mapping from the lesion cores. Multivariate lesion-symptom- and disconnectome-mapping were applied for SPN intensity and sway path as markers for AVS and AIS.
Results: AIS was diagnosed in 58%, AVS in 39%, central positional vertigo in 3% of patients. In AIS, the lesion core was located in the anterior cerebellar lobe and deep cerebellar nuclei (SCA/PICA-territory) connecting to the bilateral pontomesencephalic tegmentum via the superior cerebellar peduncle. AVS stroke lesions were mostly located in the posterior cerebellar/flocculonodular lobe (PICA/AICA-territory) and connected to the ipsilesional vestibular nucleus (VN) and bilateral medial longitudinal fascicle (MLF) via the inferior cerebellar peduncle. SPN intensity correlated with voxels in cerebellar lobules VI-IX connecting to VN and MLF. Postural sway was associated with a cluster in cerebellar Crus I.
Conclusions: AIS accounts for more than 50% of patients with stroke-related vertigo, dizziness or imbalance. AIS lesions were located in the anterior cerebellar lobe, disturbing cerebellar-pontomesencephalic networks for posture/gait control. AVS lesions predominantly affected the posterior cerebellar/flocculonodular lobe and associated vestibulo-ocular reflex networks. Recognition of both phenotypes is essential to identify all strokes among patients with vertigo and dizziness in the emergency setting.
Audiovestibular dysfunction and disease severity in Friedreich’s Ataxia
I. Zay Melville1, Miriam Rodrigues2, Juno Barnett Collins2, Andrea Thomas2, Peter R. Thorne1, Richard Roxburgh2, Rachael L. Taylor3
1Section of Audiology, School of Population Health, The University of Auckland, New Zealand
2Neurogenetics Research Clinic, Centre for Brain Research, The University of Auckland, New Zealand
3Department of Physiology, School of Medical Sciences, The University of Auckland, New Zealand
Purpose: Friedreich's Ataxia (FRDA) has been associated with hearing loss and vestibular dysfunction. However, comparisons of auditory and vestibular function in the same patients and with other disease markers are scarce.
Methods: We quantitatively assessed auditory and vestibular function in 17 genetically confirmed FRDA patients (10 female) aged 20-72 years. Testing included pure-tone and speech audiometry, auditory and vestibular evoked potentials, and video head impulse testing (vHIT). Results were compared with the shortest GAA repeat expanded allele (repeats ≤300 or >300) and disease severity measures, including the Scale for the Assessment and Rating of Ataxia (SARA).
Results: Balance issues were the initial presenting symptom for most participants (94%), while 76.5% developed hearing difficulties. Vestibular dysfunction involving the reflex pathways of the semicircular canals (horizontal=76%, anterior=73%, posterior=87%) and otolith organs (utricle=67%, saccule=54%) was identified in all but two patients. Vestibular function was not significantly correlated with hearing thresholds, and only utricular reflexes correlated with SARA scores. However, canal dysfunction on vHIT was more common and severe in patients with a test profile indicating auditory neuropathy, identified in patients with longer GAA repeat expansions.
Conclusions: Concomitant auditory neuropathy and vestibulopathy are common in FRDA, implicating involvement of the VIIIthcranial nerve. Early assessment with auditory evoked potentials and vHIT is essential to ensure timely identification and management of both conditions, particularly in patients with longer GAA repeat expansions. Research is needed to confirm the impact of early vestibular rehabilitation on balance and mobility in FRDA.
Avoid H.A.R.M. Dizziness-Stroke Measure Differentiates High-Performing from Low-Performing Hospitals Across Florida
Elizabeth Fracica, MD, MPH1, J. Matthew Austin, PhD2, Yuxin Zhu, PhD2, Krisztian Sebestyen, MS2, Najilla Nassery, MD, MPH3, David Newman-Toker, MD, PhD4
1Massachusetts General Hospital, Department of Neurology, United States
2Johns Hopkins University School of Medicine, Armstrong Institute for Patient Safety and Quality, United States
3Johns Hopkins University, School of Medicine, United States
4Johns Hopkins University School of Medicine, Department of Neurology, United States
Purpose: Stroke is the most commonly misdiagnosed condition in US emergency departments (EDs), leading to death and disability in millions of Americans annually. Vestibular strokes are at significantly increased odds of misdiagnosis, compared to those presenting with motor symptoms. Despite this, progress has been slow as research methods have traditionally been limited to the tedious review of malpractice claims or individual chart review. To move the needle on dizzy stroke misdiagnosis-related harm, we created the first reliable, claims-based, hospital-level quality measure of misdiagnosis-related harm called, “Avoid H.A.R.M.”
Methods: Using the Agency for Healthcare Research and Quality’s Healthcare Utilization Project (HCUP) all-payer claims state inpatient databases (SID) and state emergency department databases (SEDD) from 2016-2019, we calculated the Avoid H.A.R.M. dizziness-stroke harm performance measure for 216 Florida hospitals. Measure reliability was assessed using standard signal-to-noise techniques. We examined the ability of the measure to reliably distinguish “better” vs. “worse” performers.
Results: The median reliability score for the measure across the 216-hospital sample was excellent at 0.853, (IQR of 0.671-0.950). In considering hospital performance relative to the state average, 25.9% (n=56/216) of hospitals were found to be “better” than the state average (upper bound of 95% CI was less than state average for the attributable 30-day stroke harm rate), while 0.9% (n=2/216) hospitals were identified as being “worse” than the state average (lower bound of 95% CI was greater than state average). Importantly, 6.5% (n=14/216) of hospitals were identified as having statistically significant “harm” (lower bound of 95% CI was greater than zero).
Conclusions: Our research introduces the first claims-based quality measure of central vestibular stroke misdiagnosis called “Avoid H.A.R.M.” The measure accurately separates “high performers,” “low performers,” and can identify hospitals associated with significant patient harm. These findings have broad implications for healthcare consumers, regulators, payers, and policymakers.
Clinical Implications of Gaze Stability Abnormalities in People Living with Multiple Sclerosis
Colin Grove1, Brian Loyd2, Andrew Wagner3, Leland Dibble4, Michael Schubert5
1Emory University, Department of Rehabilitation Medicine, USA
2University of Montana, School of Physical Therapy and Rehabilitation Sciences, USA
3Creighton University, Department of Physical Therapy, USA
4University of Utah, Department of Physical Therapy and Athletic Training, USA
5Johns Hopkins University, Department of Otolaryngology Head and Neck Surgery, USA
Purpose: Three-quarters of the estimated 2.8 million people living with multiple sclerosis (PLWMS) worldwide may experience vestibular symptoms (e.g., oscillopsia). Yet, vestibular-mediated gaze stability (GS) mechanisms have not been extensively investigated in PLWMS. To better understand the clinical implications of impaired GS in PLWMS, we examined their GS functions relative to those of people living with vestibular deafferentation (PLWVD), documented oculomotor behaviors unique to PLWMS, interrogated the association between MS-related disability and GS dysfunction, and contrasted the effectiveness of their horizontal versus vertical GS mechanisms.
Methods: Forty PLWMS (53.9 ± 11.2 years old, 78% female, median (inter-quartile range [IQR] Expanded Disability Status Scale [EDSS] score = 3.5 [1.0]) who reported vestibular symptoms and 36 PLWVD (52.9 ± 12.3 years old, 61% female) were included. We calculated GS metrics (e.g., vestibulo-ocular reflex [VOR] gains and compensatory saccade [CS] parameters) from raw video head impulse test data, and we made between-group and between-plane comparisons by utilizing non-parametric analyses.
Results: PLWMS and PLWVD recruited covert CSs to compensate for low VOR gains and minimize gaze position error (GPE); however, overt CSs worsened GPE in > 50% of PLWMS. A large proportion of PLWMS demonstrated atypical oculomotor responses, (e.g., position correcting saccades, failure to generate CSs). Worse GPE was associated with greater disability. VOR gain was strongly associated with CS metrics, and PLWMS were five-times less effective in resolving GPE after vertical versus horizontal head impulses.
Conclusions: Low VOR gains and idiosyncratic CS abnormalities are common in PLWMS. Thus, further research should assess whether PLWMS benefit from personalized GS interventions.
Dizziness in Cognitive Impairment: a frequent syndrome with a distinct cortical atrophy pattern
Karim Felfela1, Nima Jooshani1, Denis Grabova1, Ken Möhwald2, Doreen Huppert1, Sandra Becker-Bense1, Filipp Filippopulos1, Florian Schöberl3, Max Wühr1, Marianne Dieterich2, Peter zu Eulenburg4, Andreas Zwergal2
1LMU University Hospital, German Center for Vertigo and Balance Disorders (DSGZ), Munich, Germany
2LMU University Hospital, German Center for Vertigo and Balance Disorders (DSGZ) & Department of Neurology, Munich, Germany
3LMU University Hospital, Department of Neurology, Munich, Germany
4LMU University Hospital, German Center for Vertigo and Balance Disorders (DSGZ) & Institute for Neuroradiology, Munich, Germany
Purpose: Dizziness and cognitive impairment are frequent complaints in the elderly, but a causal relationship between them remains unclear. Central vestibular and cognitive systems share common parieto-temporal and hippocampal networks, which may be affected simultaneously by neurodegeneration or vascular pathologies.
Methods: This prospective cohort study examined 200 elderly patients (age: 73.9±7.9 years), who presented to a tertiary referral centre with the chief complaint of dizziness, for cognitive and vestibular impairment, brain atrophy patterns and cerebral vascular lesion load. Patients underwent comprehensive neuro-otological assessment and neuro-psychological screening by MoCA test. Voxel-wise brain morphometry (VBM) was conducted in 143 patients with MoCA scores as a dependent variable, corrected for age. Functional connectivity analysis was performed from the core region of brain atrophy.
Results: 33.5% of patients had a MoCA score of <24 and 20.0% of |24,25| points. Patients with cognitive impairment complained more often about a persistent dizziness with a progressive course. Peripheral vestibular test results were comparable between MoCA subgroups. VBM revealed a significant correlation of MoCA scores with atrophy, especially in the right>left posterior insula, parietal lobule, superior temporal gyrus, anterior cingulate gyrus, bilateral posterolateral/anteromedial thalamus and cerebellum. The insular atrophy core positively connected to sensorimotor and salience networks and negatively to the default mode network. Analysis of insular sub-regions in dizzy patients with cognitive impairment indicated a selective atrophy in vestibular-related hubs relative to a healthy control cohort.
Conclusions: We report evidence for a rather frequent syndrome of predominantly neurodegenerative origin, which is characterized by the chief complaint “dizziness” in association with cognitive impairment, and is potentially caused by a preponderant right-sided cortical atrophy of (peri-)insular and opercular multisensory vestibular processing networks. We propose the term “Dizziness in Cognitive Impairment” (DCI) for this syndrome and advocate including cognitive screening tests in the routine work-up of elderly dizzy patients.
Efficacy of remote virtual reality application matches the gold standard treatment for Mal de Debarquement Syndrome
Catho Schoenmaekers1, Dario De Smet1, Jan Van Riel2, Andrzej Zarowski3, Choi Deblieck1, Floris Wuyts1
1Lab for Equilibrium Investigations and Aerospace, University of Antwerp, Antwerp, Belgium
2Telmio bv, Luchthavenlaan 27, Vilvoorde, Belgium
3European Institute for ORL-HNS, Sint-Augustinus hospital, Wilrijk, Belgium
Purpose: Mal de Debarquement Syndrome (MdDS) is a debilitating neuro-otological disorder where individuals consistently feel oscillatory self-motion, like being on a boat. MdDS can be triggered by motion or emerge spontaneously without obvious triggers. Treatment with full field optokinetic stripes (OKS) in a special booth, in combination with head roll at a specific frequency alleviates the symptoms in a large part of the patients, the so-called VOR re-adaptation treatment. Our objective was to develop a virtual reality application (VRA) to mimic the full field OKS booth and evaluate its efficacy compared to the standard treatment.
Methods: In our randomized open non-inferiority clinical trial with 30 MT-MdDS patients, 15 received the gold standard and 15 the new VRA, both during four consecutive days, twice a day in two four-minute blocks. Treatment effectiveness was evaluated through questionnaires and posturography.
Results: The VRA group exhibited a response rate of 73%±12%, while the booth group had a response rate of 67%±13%, being not significantly different. However, the VRA showed advantages over the booth method, in improving blurry vision and self-motion perception.
Conclusions: Our study shows that VRA treatment has the same efficacy as the gold standard OKS booth. Interestingly, the VRA showed a significantly higher improvement for blurry vision and perception of self-motion compared to the booth. Since patients can use the VRA at home, we advocate that the VRA can be used as an accessible alternative to the booth method worldwide, effectively mitigating MdDS symptoms and enhancing the QoL of numerous MdDS patients.
GALVANIC VESTIBULAR STIMULATION TO IMPROVE QUALITY OF LIFE AND AUDITORY COGNITION IN ADVANCED PARKINSON'S DISEASE
Renata Cristina Cordeiro Diniz Oliveira1, Ludmila Labanca2, Anna Paula Batista de Avila Pires2, Jordana Carvalhais Barroso2, Maria Luiza Diniz2, Paula Gabriela Zeferino Meireles2, Stefane Laura Brandão2, Denise Utsch Gonçalves2
1Universidade Federal de Minas Gerais, Graduate School, Brazil
2Universidade Federal de Munas Gerais, Graduate School, Brazil
Purpose: Galvanic Vestibular Stimulation (GVS) is a non-invasive method that can be used to stimulate the vestibular system, including vestibular sensors, vestibular nuclei, neural pathways and cortical areas that receive integrated vestibular information. The present study aims to evaluate the impact of GVS in patients with advanced Parkinson's Disease (PD) regarding cognition, mood and quality of life.
Methods: This is an experimental study with a before and after comparison. The participants were 30 patients with PD, postural instability and no dementia who underwent GVS sessions once a week for eight consecutive weeks. The intensity of the electrical current between the mastoids was gradually increased from 1.0 milliamps (mA) to 3.5 mA until the 6th session and maintained at this intensity level until the 8th session. The stimulation time was progressively increased from 9 minutes in the 1st session to 30 minutes in the 3rd session and maintained until the 8th session. The exams done before and after the intervention were P300 to test auditory cognition, Five-Digit Test to evaluate voluntary attention; Geriatric Depression Scale and PDQ-39 to report quality of life were applied.
Results: The average age was 69 years with an average disease duration of 9 years. The comparison before and after showed an improvement in quality of life in the dimensions “cognition” (p=0.012) and “communication” (p=0.013); P300 latency decreased, indicating better auditory cognition (p=0.026). Mood and performance in FDT did not change (p>0.05).
Conclusions: The improvement in cognitive attention based on P300 and the better quality of life in parameters related to the activation of the prefrontal cortex indicated that GVS can bring benefits to cognition in advanced PD. The persistence of gains after the end of the stimulation is not known so far.
Guideline for standardized approach in the treatment of the Mal de Debarquement Syndrome
Catho Schoenmaekers1, Steven Jillings1, Andrzej Zarowski2, Choi Deblieck1, Floris Wuyts1
1Lab for Equilibrium Investigations and Aerospace, University of Antwerp, Antwerp, Belgium
2European Institute for ORL-HNS, Sint-Augustinus hospital, Wilrijk, Belgium
Purpose: Mal de Debarquement Syndrome (MdDS) is a debilitating neuro-vestibular disorder. Patients experience almost continuously a perception of self-motion. This syndrome can be motion-triggered (MT-MdDS), such as on a boat, or occur spontaneously or have other triggers (SO-MdDS) in the absence of such motion. Because the pathophysiological mechanism is unknown, treatment options and symptom management strategies are limited. One available treatment protocol involves a readaptation of the vestibular ocular reflex (VOR). This study assesses the effectiveness of vestibulo-ocular reflex (VOR) readaptation in 131 consecutive patients with a fixed protocol.
Methods: We administered 131 treatments involving optokinetic stimulation (OKS) paired with a fixed head roll at 0.167 Hz over two to five consecutive days. Each day, four-minute treatment blocks were scheduled twice in the morning and afternoon. Treatment effectiveness was evaluated through questionnaires and posturography.
Results: We observed significant improvements in the visual analogue scale (VAS), MdDS symptom questionnaire, and posturography measures from pre- to post-treatment. No significant differences were found between MT- and SO-MdDS onsets.
Conclusions: Symptoms improved subjectively and objectively in patients post-treatment. The overall success rate was 64.1%, with no significant difference between MT (64.2%) and SO (63.3%). This study supports the conclusion that VOR readaptation treatment provides relief for two-thirds of MdDS patients, irrespective of the onset type. Considering the consistency in our findings, we propose a standardized treatment approach for MdDS based on the OKS with head roll paradigm.
HEARING, DEPRESSION, COGNITION AND QUALITY OF LIFE IN PATIENTS WITH PARKINSON'S DISEASE AND POSTURAL INSTABILITY
Anna Paula Batista de Avila Pires1, Jordana Carvalhais Barroso1, Ludimila Labanca2, Maria Luiza Diniz1, Paula Gabriela Zeferino Meireles1, Denise Utsch Gonçalves3
1Postgraduate Program in Speech-Language-Hearing Sciences, Federal University of Minas Gerais, Belo Horizonte, Brazil
2Medical School, Department of Speech-Language-Hearing Sciences, Federal University of Minas Gerais, Belo Horizonte, Brazil
3Medical School, Department of Otorhinolaryngology, Federal University of Minas Gerais, Belo Horizonte, Brazil
Purpose: To evaluate hearing, depression, cognitive decline and quality of life in patients with Parkinson's Disease (PD)and postural instability.
Methods: This is a descriptive study of patients with PD and postural instability who were evaluated during the period from July 2021 to April 2022 in relation to the frequency and characteristics of hearing loss. Patients with and without hearing loss were compared regarding depression, cognitive decline and quality of life.
Results: Thirty patients were evaluated, 18 (60%) of whom were men. Age ranged from 46 to 87 years, median 72 years. The time with the diagnosis of PD ranged from 1 to 15 years, median 9 years. Regarding hearing, 17 (57%) had altered hearing, 10 (59%) of whom were men. All cases of hearing loss were sensorineural, with 14 (82%) being mild loss and 3 (18%) being moderate loss. Use of hearing aids was observed in 1/17 (6%) patient. Regarding the geriatric depression scale, the median was 5 points, with 11 (37%) above 5, characterizing suspicion of depression. The overall median of the values obtained in the Parkinson's Disease Questionnaire-39 (PDQ-39) was 47.6, with the highest scores obtained in the bodily discomfort and social support dimensions and, the lowest, in the social stigma dimension. The mini mental state examination was applied to 24/30 (80%) patients, with 18 (75%) presenting values suspected of cognitive alteration. Comparative analysis between individuals with and without hearing loss was carried out, considering comorbidities, medications in use, age group, duration of illness and suspicion of cognitive impairment. Clinical relevance was observed for hearing loss and use of amantadine (p=0.077), diabetes mellitus (p=0.077) and median of 4 years of education (p=0.069).
Conclusions: Hearing loss, depression, cognitive decline and compromised quality of life were seen to be common in patients with PD and postural instability.
How good is the visually enhanced vestibulo-ocular reflex at identifying combined cerebellar ataxia and vestibulopathy?
Thomas Chang1, Rachael Taylor2, Ouday Almoukdad3, Richard Roxburgh3
1Auckland City Hospital, New Zealand
2University of Auckland, Department of Physiology, New Zealand
3University of Auckland, Neurogenetics Research Clinic, Centre for Brain Research, New Zealand
Purpose: An abnormal visually enhanced vestibulo-ocular reflex (VVOR) indicates cerebellar ataxia and bilateral vestibulopathy (CABV). However, the sensitivity and specificity of the bedside video VVOR for identifying neurological diagnoses that exhibit the CABV phenotype have yet to be determined.
Methods: Video-oculographic recordings of the VVOR were undertaken at five frequencies of manual head rotation (0.25, 0.50, 0.75, 1.00, 1.25 Hz) in 30 participants aged 34 to 79 with either cerebellar ataxia (CA), bilateral vestibulopathy (BV), or CABV. Included in the CABV group were patients with Friedreich's Ataxia (FRDA), Spinocerebellar Ataxia type 6 (SCA6) and Cerebellar Ataxia, Neuropathy and Vestibular Areflexia Syndrome (CANVAS). We compared the VVOR gains and rates of catch-up saccades with normal values obtained from 24 healthy controls.
Results: Results for the CABV group depended on the diagnosis and the severity of vestibular dysfunction. Compared with the controls, patient with CANVAS showed decreased VVOR gains and increased catch-up saccades at all frequencies. Results in FRDA and SCA6 were more variable, with patients demonstrating both normal and decreased VVOR gains. Compared with gain, catch-up saccades were a more sensitive but less specific indicator of CABV. VVOR gains were mostly within the normal range for the CA and BV groups. However, some BV patients exhibited decreasing gain and increasing rates of catch-up saccades as head rotation frequency increased above 0.50 Hz.
Conclusions: Results are consistent with the theoretical framework that considers VVOR as an additive process between vestibular and cerebellar eye movements. Although the sensitivity of the VVOR is not perfect, an abnormal VVOR at or below 0.5Hz is a specific indicator of CABV. Video-oculographic VVOR provides a useful initial assessment for someone with suspected CABV.
Illusory self-motion during MR-guided Focused Ultrasound thalamotomy for tremor
Matteo Ciocca1, Ayesha Jameel2, Nada Yousif3, Neekhil Patel1, Joely Smith4, Sena Akgun2, Brynmor Jones2, Wlayslaw Gedroyc2, Dipankar Nandi1, Yen Tai1, Barry M Seemungal1, Peter Bain1
1Imperial College London, Department of Brain Sciences, UK
2Department of Radiology, St Mary’s Hospital,Imperial College Healthcare NHS Trust, London, UK
3School of Engineering and Computer Science, University of Hertfordshire, UK
4Imperial College London, Department of Bioengineering, UK
Purpose: Brain networks mediating vestibular perception of self-motion overlap with those mediating balance. A systematic mapping of vestibular perceptual pathways in the thalamus may reveal new brain modulation targets for improving balance in neurological conditions.
Methods: Here, we systematically report how magnetic resonance-guided focused ultrasound surgery of the nucleus ventralis intermedius of the thalamus commonly evokes transient patient-reported illusions of self-motion.
In 46 consecutive patients, we linked the descriptions of self-motion to sonication power and 3-dimensional coordinates of sonication targets.
Target coordinates were normalised using a standard atlas and a 3D model of the nucleus ventralis intermedius and adjacent structures was created to link sonication target to the illusion.
Results: 63% of patients reported illusions of self-motion, which were more likely with increased sonication power and with targets located more inferiorly along the rostro-caudal axis. Higher power and more inferiorly targeted sonications increased the likelihood of experiencing illusions of self-motion by four and two times, respectively (odds ratios: 4.03 for power, 2.098 for location).
Conclusions: The phenomenon of magnetic vestibular stimulation is the most plausible explanation for these illusions of self-motion. Temporary unilateral modulation of vestibular pathways (via magnetic resonance-guided focused ultrasound) unveils the central adaptation to the magnetic field, leading to an explicable illusion of motion. Consequently, systematic mapping of vestibular perceptual pathways via magnetic resonance-guided focused ultrasound may reveal new intracerebral targets for improving balance in neurological conditions.
Incorporating Nystagmus into Caine’s Diagnostic Criteria for Wernicke’s Thiamine Deficiency
Jorge Kattah1, John Pula2
1University of Illinois College of Medicine. Peoria
2University of chicago. Northshore
Purpose: In our experience nystagmus is the most frequent ocular motor sign of thiamine deficiency (TD), and a key finding in early TD. Here, we investigate the diagnostic/prognostic value of nystagmus and vestibular evaluation in TD.
Methods: Retrospective analysis of a 23-patient acute vestibular syndrome/ataxia cohort (at risk of TD. All underwent neurovestibular examination and nystagmus recordings.
Results: Nine patients had horizontal (h) nystagmus (vestibular and/or gaze holding nystagmus). including one with combined upbeat/h nystagmus/truncal ataxia (UBN/TA) Thiamine replacement improved them within hours, also preventing Wernicke’s encephalopathy (WE). In contrast, only one UBN/TA had fast improvement. Among eleven patients with permanent downbeat/truncal ataxia DBN/TA, five initially had UBN, and converted to DBN/TA), and six late- stage patients already had DBN/TA, one patient has chronic UBN/TA for two years with slow improving WE. One patient did not have nystagmus. Thiamine prevented encephalopathy at a faster pace in the h- versus the vertical (v) nystagmus patients. None of the 23 patients developed Korsakoff’s syndrome (KS). MRIs were abnormal in 12 patients. The horizontal head impulse test (h-HIT) was bilaterally abnormal in 10 acute patients with normal vertical HIT; it was abnormal in all canals in one patient, and normal in all canals in one patient.
Conclusions: H-nystagmus and abnormal h- HIT were early signs of TD. Eleven patients developed enduring DBN/TA and had slower encephalopathy resolution. This series highlights the diagnostic role of nystagmus in TD. We propose to incorporate these observations into Caine’s diagnostic criteria focusing on early diagnosis.
Otolith organ function in CANVAS
Manju Dean1, Imelda Hannigan2, Shaun Watson2, Kishore Kumar3, Miriam Welgampola4, G Michael Halmagyi4, David Szmulewicz5
1Balance Disorders and Ataxia Service, Royal Victorian Eye and Ear Hospital, Victoria Australia
2Blacktown Neurology Clinic, NSW, Australia
3St Vincent's Healthcare, NSW, Australia
4University of Sydney/The Prince of Wales Hospital, NSW, Australia
5Balance Disorders and Ataxia Service, Royal Victorian Eye and Ear Hospital/Bionics Institute, Victoria Australia.
Purpose: CANVAS is a disease which results in imbalance and incoordination due to the triad of vestibular, cerebellar and somatosensory impairment. Our previous research has found that the primary site of vestibular pathology in CANVAS is Scarpa’s (vestibular) ganglia, noting that the end organs (both semicircular canals and otolith organs) remain unaffected. We and others have previously shown that in CANVAS the semicircular canal function is invariably reduced. This is putatively in keeping with the severe Scarpa’s ganglionopathy. Here, we sought to understand whether otolith
Methods: A multi-centre analysis of objective otolith organ function in 35 individuals with CANVAS was performed.
Results: Analysis of Vestibular Evoked Myogenic Potentials (VEMP) in 35 people with CANVAS found that approximately half had normal results.
Conclusions: This finding is of particular interest given afferent nerve fibres from both the otolith organs and the semicircular canals route via Scarpa’s (vestibular) ganglia. Potential explanations include the different sensitivities of the objective modalities utilised to measure end organ function, and potential anatomical distinctions between afferent vestibular nerve fibres.
Recent developments in combined peripheral and central vestibular disorders
David Szmulewicz1, Alex Tarnutzer2, Michael Schubert3
1The Royal Victorian Eye and Ear Hospital/Bionics Institute Melbourne, Australia
2Cantonal Hospital of Baden, Baden, Switzerland and Faculty of Medicine, University of Zurich, Switzerland
3Johns Hopkins University School of Medicine, Baltimore, MD, USA
Purpose: Combined peripheral and central vestibular disorders are a topical and increasingly common area of clinical and research interest. Novel diseases such as the recent discovery of spinocerebellar ataxia type 27B (SCA27B), which is the most common cause of inherited ataxia, identified in approximately 20% of cases. Added to CANVAS/RFC1-related disease, this increases to around 30%.
Methods: We will present a diagnostic protocol to aid in the process of identification of combined peripheral and central vestibular disease, discuss recently identified disorders and treatment including vestibular rehabilitation and occupational therapy. Evidence for specific treatment protocols and emerging treatment concepts will be critically discussed and summarized.
Results: A diagnostic protocol aids in the process of recognition and increasing the yield of definitive diagnosis. In turn, definitive diagnosis facilitates prognostication, specific management, family planning and access to current and future treatment trials. Many combined peripheral and central vestibular disorders have multiple and emerging phenotypes. Additionally, peripheral vestibular involvement in known central vestibular diseases is increasing.
Conclusions: Current treatment of this patient group involves a multi-disciplinary approach, and given the significant drug pipeline, pharmaceutical trials are imminent. This information is relevant to all clinicians who consult on patients with potential vestibular and/or cerebellar disease as well as researchers in this area.
Revealing the underlying pathophysiological mechanisms of MdDS with the use of functional magnetic resonance imaging
Catho Schoenmaekers1, Steven Jillings1, Megan Van Deun1, Andrzej Zarowski2, Floris Wuyts1
1Lab for Equilibrium Investigations and Aerospace, University of Antwerp, Antwerp, Belgium
2European Institute for ORL-HNS, Sint-Augustinus hospital, Wilrijk, Belgium
Purpose: Mal de Debarquement Syndrome (MdDS), recognized as a neuro-vestibular disorder in 2020, manifests with subjective sensations of self-motion, typically triggered by e.g. sea or air travel. Although its exact pathophysiology remains elusive, MdDS symptoms are associated with maladaptation of the vestibulo-ocular reflex (VOR). Optokinetic stimulation (OKS) significantly alleviates symptoms by stimulating the velocity storage mechanism, correcting VOR maladaptation. This study aims to 1) enhance the understanding of MdDS pathophysiology and the effect of OKS treatment using resting-state functional magnetic resonance imaging (rs-fMRI) pre- and post-OKS treatment and 2) examine the correlation between changes in posturography measures and functional connectivity changes in specific vestibular cortical regions.
Methods: The study included 30 MT-MdDS patients who were treated for four consecutive days (Tuesday through Friday).rs-fMRI scans were collected on Sunday and Friday evening within the same week. FC was derived using a cortical vestibular atlas-based region-of-interest (ROI) approach. Correlation between pre- to post-treatment rs-fMRI and posturography differences was examined (p<0.001 uncorrected, cluster-level p<0.05 FDR corrected).
Results: The rs-fMRI showed increased connectivity in cerebellar crus I/II post-treatment and decreased connectivity between cerebellar lobule X and left middle temporal gyrus. Additionally, correlations were found with posturography and symptom severity. These changes not only objectify OKS treatment impact, but point towards possible brain ROI’s involved in the pathophysiology of MdDS.
Conclusions: Connectivity changes post-treatment indicate that OKS treatment has a measurable impact in certain ROI’s in the brain. Additionally, decreased connectivity correlated with more severe symptoms, suggesting its potential as a biomarker for MdDS severity.
Small Vessel Disease underlies the emergence of Idiopathic Dizziness in the Elderly
Adolfo Bronstein1, Patricia Castro1, Richard Ibitoye1, Diego Kaski2, Toby Ellmers1
1Imperial College London, Department of Brain Sciences
2University College London Hospitals
Purpose: A significant proportion of elderly dizzy patients remain undiagnosed – essentially no vestibular, neurological or cardio-vascular explanation for their dizziness is found. Recent work indicates that white matter small vessel disease (SVD) underlies this syndrome of idiophatic dizziness of the elderly (IDE). Ahmad et al (J Neurol Sci 2015) found that the proportion of patients with severe SVD (Fazekas 3) was significantly higher in the idiopathic (IDE) group. A prospective MRI study identified greater white matter hyperintensity and lower fractional anisotropy in balance-related brain areas, such as deep frontal white matter, genu of the corpus callosum and the inferior longitudinal fasciculus – areas relevant to gait/balance control (Ibitoye et al Neuroimage Clin 2022). Increased EEG desynchronization on standing up and changes in connectivity in IDE patients, over and above that seen in the elderly, suggest that the dizzy patients' brain is biologically older than that of non-dizzy controls (Ibitoye et al Clin Neurophys 2021). Further work by Castro et al (this meeting) reports a distorted perception of instability and subtle impairments in balance control in IDE patients (including abnormalities of the protective stepping response), partly predicted by SVD load.
Methods: We will summarise these recent experiments and present a novel analysis of EEG during standing balance in 36 IDE patients and age-matched controls.
Results: Experiments show that EEG timelocked to instances of peak instability revealed substantial beta and low gamma de-synchronisation for patients in the leg motor cortex, suggestive of a more sensitive/over-responsive postural system in IDE patients.
Conclusions: Clinical, MRI and EEG data support the view that SVD underlies the emergence of dizziness in the elderly by disrupting brain postural loops. We propose the acronym MAID (Micro-Angiopathy Induced Dizziness) to describe these patients.
Vestibular and visual impairments and associations with walking and balance in people with Multiple Sclerosis
Katrina L Williams1, Sandra G Brauer1
1The University of Queensland, Brisbane Australia
Purpose: To investigate vestibular and oculomotor manifestations in people with Multiple Sclerosis (MS) and explore relationship to clinical gait outcomes and self-reported walking, balance confidence and MS impact, in a whole cohort and disability subgroups.
Methods: A prospective, single test session, observation study was conducted with 41 ambulant people with MS. Oculomotor and vestibular function was captured using a binocular video capture system embedded within the micromedical visualeyes V505, video frenzels (Interacoustics) and Video Head Impulse Test (ICS Impulse). Tests included oculomotor (nystagmus and ocular-motility) and vestibular (6 semi-circular canal gain) measures. Gait speed (Timed-10m-walk), gait balance (Timed-Up and Go), endurance (6-Minute walk test) and self-reported gait (Multiple Sclerosis Walking Scale-12), balance confidence (Activity Balance Confidence Scale), MS impact (Multiple Sclerosis Impact Scale-29) and dizziness (Dizziness Handicap Inventory) were recorded. Gait disability, Disease Step (DS), was used to divide participants into high (DS3-5) and low disability subgroups (DS0-2). Correlations were explored for the whole cohort and subgroups.
Results: Few significant relationships were identified-for the full cohort, however the less disabled subgroup showed more and stronger correlations for dizziness and semi-circular canal gains to gait speed and balance (r2range -0.39 to -0.49; p<0.04), oculomotor to gait measures (r2range 0.40 to 0.58; p<0.05) and dizziness to self-reported gait, balance and impact (r2range -0.68 to 0.50; p<0.05). Different and stronger correlations were identified for the more disabled subgroup for the semi-circular canal gain to gait balance (r2range -0.53 to -0.61; p< 0.04) and self reported balance confidence (r20.54 & 0.70; p<0.03).
Conclusions: Disability level had an effect on the correlations between vestibular and oculomotor function to clinical/self-reported gait and balance. Vestibular and oculomotor impairments are important to measure in people with MS as they vary by disability level. Addressing these impairments may influence gait/balance function.
Vestibular event monitoring for posterior circulation stroke: in the emergency room and beyond
Gülden Akdal1, Benjamin Nham2, Belinda Kwok3, Allison Young4, Chao Wang5, Pınar Özçelik6, Rahmi Tümay Ala1, Deborah Black7, Süleyman Men8, Kristen Steenerson9, Gabor Michael Halmagyi10, Miriam Welgampola10
1Dokuz Eylül University School of Medicine, Department of Neurology, İzmir, Türkiye
2School of Medicine, St George and Sutherland Clinical Campus, University of New South Wales, Sydney,Australia
3Central Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia, 3
4Director of Professional Practice Ears To You Nanaimo, BC, Canada
5Institute of Clinical Neurosciences, Royal Prince Alfred Hospital, Sydney, Australia
6Bezmialem Vakıf University, Department of Neurlogy,İstanbul,Türkiye
7Faculty of Medicine and Health, University of Sydney, Sydney, Australia
8Dokuz Eylül University School of Medicine, Department of Radiology, İzmir, Türkiye
9Stanford University, School of Medicine, Department of Neurology, San Fransisco, USA
10Neurology Department, Royal Prince Alfred Hospital, Sydney, Australia
Purpose: Recording ictal-nystagmus is an important part of the HINTS assessment, which in turn helps separate posterior-circulation stroke and vestibular neuritis.
Methods: Eighty patients presenting to the emergency-room with acute vestibular syndrome underwent ictal video-nystagmography on presentation and over 3-9 days in the stroke-unit. Nystagmus slow-phase velocity (SPV) and direction were recorded.
Results: Stroke territories included posterior-inferior cerebellar artery (PICA, n=33), anterior-inferior cerebellar artery (AICA, n=5), superior cerebellar artery (SCA, n=2) and brainstem-perforators (n=22).
Twenty-one and three PICA infarcts demonstrated horizontal and vertical spontaneous nystagmus on consecutive recordings, while 9 had no nystagmus; two of 5 AICA patients demonstrated vertical nystagmus and 3 had horizontal nystagmus. Neither of 2 patients with SCA strokes had ictal nystagmus. Basilar perforator infarctions showed no nystagmus (n=3) on multiple recordings, horizontal nystagmus (n=9) or vertical nystagmus. Midbrain perforator infarcts showed either horizontal nystagmus (n=2), vertical nystagmus (n=1) or no nystagmus (n=3) on multiple recordings.
Nystagmus horizontal SPV on day 1 was 3.3° ± 4.9° (range 1.34 °-29.80°). Vertical SPV was 3.3° ± 7.2° (range 1.2°-43.9°). The overall prevalence of gaze-evoked nystagmus was 38%; 24, 40 and 14% of PICA, AICA and brainstem-perforators showed gaze-evoked nystagmus. 21, 40 and 23 % of PICA, AICA and brainstem-perforator strokes demonstrated direction changing nystagmus; 11 % of strokes that presented with no nystagmus later demonstrated nystagmus between days 3-6.
Conclusions: Nystagmus directions in posterior-circulation stroke do not follow conventional expectations of “typical central-nystagmus”. Serial examinations yield nystagmus that was not evident at ictus or changes in nystagmus direction
Vestibular prepulse inhibition of the human blink reflex
Ciocca Matteo1, Sarah Hösli1, Zaeem Hadi1, Yen Tai1, Barry M Seemungal1
1Imperial College London, Department of Brain Sciences, UK
Purpose: Auditory and somatosensory prepulses are commonly used to assess prepulse inhibition (PPI).
The effect of a vestibular prepulse upon blink reflex (BR) excitability has not been hitherto assessed.
Methods: Twenty-two healthy subjects and two patients with bilateral peripheral vestibular failure took part in the study. Whole body yaw rotation in the dark provided a vestibular inertial prepulse. BR was electrically evoked after the end of the rotation.
The area-under-the-curve (area) of the BR responses (R1, R2, and R2c) was recorded and analysed.
Results: A vestibular prepulse inhibited the R2 (p < 0.001) and R2c area (p < 0.05). Increasing the angular acceleration did not increase the R2/R2c inhibition (p>0.05). Voluntary suppression of the vestibular-ocular reflex did not affect the magnitude of inhibition (p>0.05). Patients with peripheral vestibular failure did not show any inhibition.
Conclusions: Our data support a vestibular-gating mechanism in humans.
Significance: The main brainstem nucleus mediating PPI – the pedunculopontine nucleus (PPN) – is heavily vestibular responsive, which is consistent with our findings of a vestibular-mediated PPI. Our technique may be used to interrogate the fidelity of brain circuits mediating vestibular-related PPN functions. Given the PPN’s importance in human postural control, our technique may also provide a neurophysiological biomarker of balance.
Highlights:
• This is the first report of a vestibular prepulse inhibition of the blink reflex.
• A vestibular prepulse inhibits the R2/R2c area in healthy subjects but not in patients with bilateral peripheral vestibular failure.
• Vestibular PPI is a potential neurophysiological marker of vestibular-motor integration at the brainstem level.
Vestibulo-Ocular reflex, balance and gait impairment in people with Multiple Sclerosis
Leonardo Manzari1, Laura Casagrande Conti2, Amaranta Soledad Orejel Bustos2, Nicole Ferri3, Tommaso Lelli2, Ugo Nocentini2, Maria Grazia Grasso2, Paolo Pillastrini4, Marco Tramontano5
1MSA ENT ACADEMY Center, Cassino, Italy
2Santa Lucia Foundation, Scientific Institute for Research and Health Care, Rome, Italy
3Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
4Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
5Department of Biomedical and Neuromotor Sciences (DIBINEM), Alma Mater University of Bologna, Bologna, Italy
Purpose: Multiple Sclerosis (MS) is the most prevalent autoimmune neurological condition in the world, leading to significant disability. Rehabilitation plays a key role in the standard of care, and vestibular rehabilitation being a promising approach for related balance and gait disorders. To date, no study has correlated alterations in the vestibulo-ocular reflex (VOR) with clinical scales for balance assessment, laying the rationale for new rehabilitative training. This study aims to correlate the VOR gain of the horizontal and vertical semicircular canals through both Head Impulse (HIMP) and Suppression HIMP (SHIMP) paradigms and the scores of the clinical scale for balance and gait evaluation in people with MS.
Methods: This is an observational study; all participants were assessed on disability and balance function with the Expanded Disability Status Scale (EDSS), Berg Balance Scale (BBS) and Mini-BESTest (MBT), and the vestibular function was objectively measured by video Head Impulse Test (vHIT), obtaining the actual gain of the VOR for each semicircular canal. We performed descriptive statistics and Spearman’s correlation between vHIT scores and balance scales.
Results: Twenty-seven PwMS (mean age 47.93 ± 8.51 years old, 18 females) were involved in this study. Most of the enrolled patients (81.48%) presented abnormal VOR gains for at least one semicircular canal. A moderate to strong correlation between VOR gains of the left anterior semicircular canal, and respectively, the MBT and the BBS was found.
The subgroup analysis, based on the EDSS class, confirmed this correlation for the patients with the most significant disability and the BBS.
Conclusions: An abnormal vestibular function is highly prevalent in our sample, finding both hyper and hypo-gains. The correlation between these values and the balance scales supports the importance of considering vestibular assessment and specific rehabilitative treatment in PwMS. Studies on larger samples are needed to confirm these preliminary results.
Video Head Impulse Test and Vestibular Evoked Myogenic Potentials in Degenerative Parkinsonism
Pınar Özçelik1, Koray Koçoğlu2, Hatice Eraslan Boz2, Müge Akkoyun2, Beril Dönmez Çolakoğlu3, Raif Çakmur3, Gabor Michael Halmagyi4, Gülden Akdal3
1Bezmialem Vakıf University Medical School, Neurology, İstanbul, Türkiye
2Dokuz Eylul University, Institute of Health Sciences, Neurosciences, İzmir, Türkiye
3Dokuz Eylul University Medical School, Neurology, İzmir Türkiye
4Royal Prince Alfred Hospital, Neurology, Sydney, Australia
Purpose: Previous studies on vestibular involvement in degenerative parkinsonism give conflicting results. We aimed to find out if the video head impulse test (v-HIT) and vestibular evoked myogenic potentials (VEMP) differ between patients with Parkinson's Disease (PD), Progressive Supranuclear Palsy (PSP) and Multisystem Atrophy (MSA).
Methods: We studied 15 patients with PD, 9 with PSP and 6 with MSA and 37 age matched healthy controls (HCs). Motor functions were evaluated with the Unified Parkinson's Disease Rating Scale(UPDRS). Vestibular function was evaluated using the v-HIT test to evaluate the 6 semicircular canals (SCCs) and cervical VEMP (c-VEMP) and ocular VEMP(o-VEMP) to both air conducted sound (AC) and bone conducted vibration (BC).
Results: UPDRS motor scale did not differ between groups. VOR gains in the posterior SCCs of the PD and MSA groups were lower than in HCs. PD group also had lower VOR gain in the lateral SCCs than HCs. Both AC and BC c-VEMP amplitudes in PD and MSA were lower than HCs. In all groups, more participants responded to BC (n:59) than AC (n:50) in c-VEMP. The o-VEMP response was absent in MSA. In PD and PSP o-VEMP amplitudes were lower than in HCs. Response latencies in both c-VEMP and o-VEMP results did not differ between groups.
Conclusions: PD and MSA differ have lower VOR gain in posterior SCCs in v-HIT than from PSP and lower amplitude in c-VEMP than HCs. These results suggest involvement of central vestibular structures in some patients with degenerative Parkinsonism.
Video head impulse testing saccade metrics in neurodegenerative cerebellar ataxias
Orit Samuel1, David Szmulewicz2
1The Bruce Rappaport Faculty of Medicine, The Technion/Unit of Otoneurology, Lin Medical Center, Haifa, Israel
2Balance Disorders and Ataxia Service, Royal Victorian Eye and Ear Hospital/Bionics Institute, Victoria Australia.
Purpose: The video head impulse test (vHIT) has principally been applied to the diagnosis of peripheral vestibular disease. The presence of reverse (aberrant) corrective saccades was identified in people who had suffered cerebellar strokes. To date, the presence of saccadic abnormalities in a broader range of cerebellar disorders has been lacking. This study aims to elucidate the vHIT findings in a broad range of neurodegenerative cerebellar diseases.
Methods: A retrospective analysis of 96 patients from the Royal Victorian Eye and Ear Hospital’s Balance Disorders and Ataxia Service. All patients had a diagnosis of genetic or idiopathic cerebellar ataxia and underwent routine HIT as part of the clinic’s standard diagnostic battery. vHIT data including VOR gain, saccade metrics as well as demographic information were retrieved. Data was then analyzed to assess vestibular function including the presence of abnormal corrective saccades which were correlated with a number of parameters including diagnosis, patient age, age at disease onset, disease duration and where relevant repeat expansion number.
Results: Analysis revealed a significant disparity in vHIT gain among ataxia patients with varying diagnoses. For example, the vHIT gain was notably diminished in CANVAS patients (mean 0.29 ± 0.19) followed by iCABV (mean 0.61 ± 0.16). Moreover, corrective saccade analysis revealed nuanced characteristics of vestibular dysfunction, with reversed saccades which tend to display increased latency, low amplitude, and prolonged duration.
Conclusions: Comprehensive vHIT data retrieval and analysis has disclosed novel insights into vestibular dysfunction in neurodegenerative cerebellar diseases. The application of vHIT may now be extended to those with a range of cerebellar ataxias. High sensitivity in quantitative assessment of subtle vestibular abnormalities make vHIT an indispensable tool in both clinical practice and in the research of peripheral and central vestibular diseases. This work adds to the expanding armamentarium of objective diagnostic and biomarker modalities available for complex vestibular disorders.
7. Clinical Testing for Vestibular Function
Application of the Barany Society's Presbyvestibulopathy Criteria in Older Adults With Chronic Dizziness
Joon-Pyo Hong1, Min-Beom Kim1
1Sungkyunkwan University School of Medicine/Kangbuk Samsung Hospital, Department of Otorhinolaryngology–Head and Neck Surgery, Republic of Korea
Purpose: To evaluate the older adults with chronic dizziness using the Barany Society's presbyvestibulopathy (PVP) diagnostic criteria and to assess the clinical usability of the criteria.
Methods: This is a retrospective study from a single tertiary medical center. Among a total of 1964 patients aged 60 years or older, 55 patients who had symptoms suitable for then PVP criteria and who underwent all 3 vestibular function tests were analyzed. Of these 55 patients, 13 patients were diagnosed with PVP based on the peripheral vestibular hypofunction criteria; the remaining 42 patients were categorized as patients without PVP.
Results: In both patients with PVP and patients without PVP, postural imbalance or unsteadiness was the most frequently reported vestibular symptom. The rotatory chair test contributed the most to the quantitative diagnosis of PVP (6 of 13), followed by the caloric response test (3 of 13) and video head impulse test (vHIT; 2 of 13). When we included the presence of catch-up saccades in addition to the vHIT gain in the diagnostic criteria, 5 patients without PVP were additionally diagnosed with PVP. Furthermore, when accounting for the inclusion of catch-up saccades, patients who experienced recurrent falls demonstrated a significantly higher rate of impairments in the lateral and posterior semicircular canals according to the multivariate analysis.
Conclusions: Considering the catch-up saccades in addition to vHIT gain seemed to contribute to the diagnosis of PVP and prediction of recurrent fall risks in older adults. Further studies are needed to solidify the diagnostic criteria for PVP.
Assessment of the vestibular function in elderly rehabilitation patients using vHIT
Liyona Kampel1, Ron Cialic2, Orly Barak2, Omer Ungar1, Ophir Handzel1, Rani Abu Eta1, Yahav Oron1
1Tel Aviv Sourasky Medical Center, Department of Otolaryngology Head and Neck Surgery and Maxillofacial Surgery, Israel
2Tel Aviv Sourasky Medical Center, Geriatric Division and Department of Rehabilitation, Israel
Purpose: Recurrent falls in elderly patients frequently result in lengthy hospitalizations, psychological distress, and physical debilitations. Unsteadiness in the aging population is multifactorial, with age-related decline of the vestibular function being one possible cofactor. Yet, semi-circular canal dysfunction is hard to detect as physical signs may be subtle. We aimed to assess the prevalence of vestibular dysfunction in the elderly population using the reliable video head impulse test (vHIT).
Methods: Elderly patients (> 70 years old) admitted to the rehabilitation hospital were evaluated with a vHIT to assess the gain of three dimensional vestibulo-oculomotor reflexes (VOR). Vestibular function was analysed in relation to age, the cause of hospitalization and comorbidities.
Results: Twenty patients were included in the study, of whom 25% had pathologic gain of the horizontal canal VOR (<0.7). The mean gain of the horizontal canals VOR of the entire cohort was 0.93 ± 0.26. Patients < 80 years had a mean gain comparable to those ≥80 years (1.01 vs. 0.89, respectively, p = 0.364), but age ≥80 years was significantly associated with pathologic VOR gain (OR 7.2 [95% CI 0.66-96], p = 0.044). A tendency towards pathologic VOR gain was observed when cardiovascular risk factors existed (p = 0.08). Pathologic VOR gain was more common among patients rehabilitated due to fall injuries compared to other causes (p = 0.038).
Conclusions: Pathologic VOR gain was observed in approximately 50% of elderly patients ≥80 years old. Our results indicate that vestibular dysfunction may be a significant risk factor for falls in the elderly, suggesting interventional measures should be considered.
Audiovestibular findings and tumor size in patients with vestibular schwannoma with and without asymmetric hearing loss
Kathrin Skorpa Nilsen1, Frederik Kragerud Goplen1, Jan Erik Berge1
1Haukeland University Hospital, ENT department, Norway
Purpose: To study the prevalence of abnormal vestibular tests and audiovestibular symptoms in patients with newly diagnosed vestibular schwannoma (VS) with and without asymmetric hearing loss.
Methods: National cross-sectional study of newly diagnosed vestibular schwannoma patients undergoing wait-and-scan management. Inclusion from 2017 to 2019. Main outcomes: Prevalence of canal paresis and abnormal cervical vestibular evoked myogenic potentials (cVEMP). Asymmetric hearing loss was defined as asymmetry ≥ 15 dB at 3000 hz between the two ears. Baseline data with MRI, dynamic posturography, bithermal caloric tests and cVEMP. Questionnaire data on dizziness and tinnitus.
Results: (Preliminary). The study included 129 patients with mean age 55 (range 28 to 77) years. Asymmetric hearing loss was found in 85 patients (66 %). In the group with and without asymmetrical hearing loss, canal paresis was present in 53 % and 39 %, respectively, abnormal cVEMP was present in 38 % and 36 %, respectively, posturographic unsteadiness was present in 33 % and 32 %, respectively and median maximal diameter was 12 mm and 8 mm, respectively.
Conclusions: Canal paresis and cVEMP asymmetry is present in a significant proportion of VS patients that would not qualify for MRI based on hearing asymmetry according to current criteria for imaging.
Bias-Probe Yaw-axis Rotation Tests for Identification of Asymmetric Vestibular Function
Robert Peterka
1
1Oregon Health & Science University, Department of Neurology, United States
Purpose: Two rotation tests for the improved identification of asymmetric vestibular function are reintroduced. Both tests are multi-cycle periodic rotational stimuli that include a higher-amplitude, lower-frequency ‘bias’ component and a lower-amplitude, higher-frequency sinusoidal ‘probe’ component. The bias component drives a portion of lateral canal afferents to silence during the inhibitory half of the rotation cycle. Because VOR eye movements depend on afferent information from both ears, when canal function is absent in one ear then rotation toward that ear will largely silence activity in the functioning ear resulting in reduced net afferent activity and therefore reduced probe-related modulation of VOR eye movements.
Methods: A ‘Two Sine’ test included two sinusoidal components with a 0.1 Hz bias component with peak amplitudes up to 250°/s and 1 Hz, 20°/s probe component. A ‘Pulse-Step-Sine’ (PSS) test with a 10-s cycle duration used a bias component consisting of a short (∼1 s) higher-amplitude pulse of acceleration followed by a lower-amplitude, longer-duration step of acceleration with a 1-Hz, 20°/s probe component superimposed on the step component. Both tests were performed in the dark and also with fixation suppression.
Results: The slow phase velocity of VOR-evoked eye movements in unilateral vestibular loss participants revealed increasing evidence of the side of their loss as the amplitude of the bias component was increased. Vestibular asymmetry was evident in responses related to both the bias and probe components of the stimulus. Fixation suppression tests had some advantage with the lower eye velocities allowing for more consistent calculation of slow phase eye velocity.
Conclusions: The analysis of VOR eye movements evoked by periodic yaw-axis bias-probe rotational stimuli identified the presence and side of vestibular loss. Additionally, simulation results indicated that variations in the step component amplitude of PSS stimuli could be used to identify the time constant of semicircular canal afferents.
Caloric-impulsive test dissociation: think Méniére’s disease. (Bárány wins)
Miranda Morrison1, Diego Herrero1, Nicole Reid1, Belinda Kwok1, Michael Todd1, G. Michael Halmágyi1, Miriam Welgampola1
1Royal Prince Alfred Hospital, Neurology Department, Sydney Australia
Purpose: To analyse the clinical diagnoses in vertigo patients with unilateral impairment of lateral semicircular canal function on caloric testing but normal lateral semicircular canal function on horizontal head impulse testing (caloric-impulsive test dissociation).
Methods: We reviewed the video head impulse test (vHIT) results of all patients who had caloric testing over 10 years (Dec 2013 to Dec 2023) and had a unilateral caloric canal paresis --->25% (with warm and cool nystagmus slow phase velocities >20 deg/s from the better ear). Normal vHIT gain was set between 0.8 and 1.1 and only results of tests performed less than a month apart were analysed.
Results: In 10 years, 3206 patients had caloric testing: 696 of them met our selection criteria (canal paresis of >25%; warm and cool slow phase velocity >20deg/s from the better ear). Of these 696, 165 (56%) had normal lateral canal vHIT gains. Of these 165, 92 had Méniére’s disease (69 definite, 23 probable), 17 previous acute vestibular neuritis (8 definite and 9 probable), 29 were thought to have Vestibular Migraine, 4 had a Vestibular Schwannoma, 4 had only benign positional vertigo and the remaining 19 had various other diagnoses.
Conclusions: Of our 165 patients with caloric-impulsive test dissociation, 92 (56%) had either definite or probable Méniére’s disease. The others mainly had previous acute Vestibular Neuritis or had Vestibular Migraine. This result confirms that in a vertigo patient with caloric-vHIT dissociation, Méniére’s disease is the likely diagnosis.
Capturing Nystagmus During Vertigo Attacks Using a Smartphone: Adherence, Characteristics and Pearls & Pitfalls
Ali Melliti1, Maurice van de Berg1, Raymond van de Berg1
1Maastricht University Medical Center
Purpose: To investigate adherence, characteristics, and first clinical experiences of capturing ictal nystagmus at home, which can be performed to complement the diagnostic process in patients with episodic vestibular symptoms.
Methods: Patients were recruited in case capturing ictal nystagmus could contribute to the diagnostic process (e.g. to detect or rule out BPPV). They were asked to capture ictal nystagmus with their own smartphone at home, using a smartphone-based adapter (Nystagmocatcher, Balansdiagnos, Stockholm, Sweden). All recordings were analyzed.
Results: Sixty-two patients participated in this study. The median period of participation was 86 days. Fifty-one patients experienced attacks during the study period. Eventually, 51% of them provided eye movement recordings sufficient for analysis. Different types of nystagmus were observed: positional nystagmus related to BPPV, positional nystagmus not related to BPPV, functional eye movements, and the absence of nystagmus or functional eye movements.
Capturing ictal nystagmus could contribute to the diagnostic process in several ways, including: to detect or rule out BPPV, to detect or rule out vestibular origin of symptoms, to determine the affected side, telemedicine, to monitor attack frequency, and to detect malingering. Furthermore, strict guidance of patients was necessary, which could be time consuming.
Conclusions: Capturing ictal nystagmus can contribute to the diagnostic process in several ways, which motivates to rethink current clinical workflow in vestibular medicine. However, strict guidance is necessary and not all patients provide ictal recordings. In an outpatient setting, it would be advised to use ictal nystagmus recordings on indication, to complement the diagnostic process.
Clinical utility of high frequency head shake test in vertigo practice
Prateek Porwal1, Srinivas Dorasala2, Avinash Bijlani3
1ENT and Vertigo Specialist, PRIME ENT Center, UP, INDIA
2Ear, Nose and Throat (ENT) Department, Jawaharlal Nehru Medical College (JNMC), Belagavi, Karnataka, INDIA
3Senior Vertigo specialist, Madhav ENT Center, New Delhi, INDIA
Purpose: The head-shaking nystagmus (HSN) test, particularly at high frequencies, is a diagnostic tool used to assess vestibular function by identifying imbalances in the vestibular system. The purpose of this study was to determine the clinical utility of the head shake test.
Methods: In this study, 210 patients underwent horizontal head shake testing with the videonystagmography device. The test involves rapid horizontal shaking of the head while monitoring eye movements using videonystagmography. It's performed in a dark room to eliminate visual fixation.
Results: In patients with unilateral vestibular loss such as vestibular neuritis, nystagmus typically beats towards the healthy side. In central nervous system disorders, the direction of nystagmus can be non-localizing or exhibit complex patterns like biphasic or perverted nystagmus. The presence of HSN can indicate ongoing vestibular compensation or reveal underlying abnormalities not apparent without provocation. HSN can help in diagnosing conditions like cerebellar degeneration, multiple system atrophy and other central lesions, where abnormal nystagmus patterns such as torsional or perverted nystagmus may appear.
Conclusions: The high-frequency head-shake test is a valuable diagnostic tool in neurotology, capable of revealing subtle vestibular dysfunctions and aiding in the diagnosis of both peripheral and central vestibular disorders.
Clinical value of bedside HIT in the assessment of vertical semicircular canals impairment and its concordance with vHIT
Salvatore Martellucci1, Andrea Castellucci2, Pasquale Malara3, Rudi Pecci4, Marco Mandalà5
1ENT Unit, Santa Maria Goretti Hospital, Azienda USL di Latina, Italy
2ENT Unit, Department of Surgery, Azienda USL—IRCCS di Reggio Emilia, Italy
3Audiology & Vestibology Service, Centromedico, Bellinzona, Switzerland
4Audiology Unit, AOU Careggi, Department of Surgery and Translational Medicine, University of Florence, Italy
5Department of Medicine, Surgery and Neuroscience, University of Siena, Italy
Purpose: The bedside-head impulse test (bHIT) aims to qualitatively assess the lateral semicircular canal (SC) function in response to horizontal, small-amplitude and high-acceleration head impulses, and it is included in the HINTS protocol to distinguish peripheral from central acute vestibulopathies (AVPs). The introduction of the video-HIT (vHIT) has provided a quantitative functional assessment of both lateral and vertical SCs, allowing the identification of peculiar SC lesion patterns (SCLP). Nevertheless, it is also possible to qualitatively test the vertical SCs activity through vertical bedside head impulses along the LARP and RALP planes. This study aims to assess the reliability of the bHIT performed on the three planes (horizontal, LARP and RALP) in identifying the SCLP in peripheral AVPs.
Methods: We prospectively enrolled 55 patients (29 male, 26 female, mean age 56±7) presenting with or without spontaneous nystagmus due to a peripheral AVP occurred within the previous month. All patients received a bedside examination including the HINTS protocol and the bHIT along the three planes, recorded using a video-camera in front of the patient. Then, the bHIT-recordings were blindly reviewed by 5 neurotologists who were asked to indicate the corresponding SCLP. Finally, vHIT, cervical/ocular-VEMPs and audiometry were performed. All SCLPs estimated by the bHIT were collected and compared with the SCLPs obtained with the vHIT.
Results: The agreement between bHIT and vHIT results and between the responses of each examiner was expressed by Cohen's «Kappa» index. A highly significant concordance between bHIT results and vHIT data (p<0.000, Cohen's kappa=0.85) was detected within 10 days from symptoms onset, with similar statistical concordance between the examiners (p<0.05). The concordance dropped in the subacute phase (>10 days) and was not significant in cases without spontaneous nystagmus.
Conclusions: Vertical SC bHIT seems a reliable test in the acute stage of AVP, supporting the identification of the underlying SCLP.
Development of Head-Mounted-Display (HMD)-based Oculography, Available for Clinical and Experimental Use
Takeshi Tsutsumi1, Natsuki Aoki1, Ayame Yamazaki1, Takamori Takeda1, Keiji Honda1
1Department of Otorhinolaryngology, Tokyo Medical and Dental University
Purpose: The recent emergence of a super-aging society in Japan has led to an increasing number of vestibular falls, resulting in a decline in the quality of life and elevated social and economic burdens. Addressing these issues requires implementing preventive interventions in residential areas. An affordable oculography device, coupled with data sharing capabilities for telemedicine, empowers local clinics to deliver specialized medical services within their communities. Moreover, understanding the fundamentals and developing new parameters for gravity perception in daily life are crucial challenges.
Methods: We have developed an affordable HMD-based oculography system, which facilitates data sharing through a cloud server. This system is designed to allow for the easy development and integration of new menus and is also suitable for experimental use.
Results: Our device enables the efficient completion of the standard battery of neurotological examinations, with the outcomes readily shared on the cloud server. Additionally, we have initiated a consultation service for expert interpretation of the results, marking the inception of remote medicine. We are also actively developing supplementary examination menus, including vHIT, OCR, SVV, Lissajous trajectory tracking, fixation stability tests, free-viewing tests, and vestibular rehabilitation. Furthermore, we are engaged in various basic research endeavors utilizing this device, investigating gravity perception through 3D eye movements during and after rotational stimulation, as well as Coriolis stimulation.
Conclusions: The HMD device emerges as an excellent platform, serving as a valuable and cost-effective oculography tool for clinical use. Additionally, it proves to be a convenient instrument for basic research and development purposes.
Diagnostic accuracy of a graded gait and truncal instability rating in acute dizziness – systematic review
Carlos Martinez1, Zheyu Wang2, Sergio Carmona3, Jorge Kattah4, Alexander Andrea Tarnutzer5
1Hospital Jose Maria Cullen, Santa Fe, Argentina
2Division of Quantitative Sciences, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, USA
3Fundación San Lucas para la Neurosciencia, Rosario, Argentina
4University of Illinois College of Medicine, Peoria, IL
5Cantonal Hospital of Baden, Neurology, Baden, Switzerland
Purpose: In patients presenting with acute prolonged vertigo and/or gait imbalance, the HINTS [Head-Impulse, Nystagmus, Test-of-Skew] are very valuable. However, their application may be limited by lack of training and absence of vertigo/nystagmus. Alternatively, a graded gait/truncal-instability (GTI, grade 0-3) rating may be applied.
Methods: We performed a systematic search (MEDLINE, Embase) to identify studies reporting on the diagnostic accuracy of bedside examinations in adults with acute vestibular syndrome. Diagnostic test properties were calculated for findings using a random effects model. Results were stratified by GTI-rating used.
Results: We identified 6515 citations and included 17 articles (n=904 patients). Ischemic strokes (n=613) and acute unilateral vestibulopathy (n=237) were most frequent. Grade 2/3 GTI had moderate sensitivity (69.8% [95% confidence-interval (CI)=57.3-82.3%]) and specificity (79.2 [61.4-97.0%]) for predicting a central cause, whereas grade 3 GTI had a lower sensitivity (42.7% [32.8-52.6%] and higher specificity (99.0% [97.8-100.0%]). In comparison, diagnostic accuracy of HINTS (sensitivity=97.3% [95.4-99.2%]; specificity=96.1% [93.2-98.9%]) was higher. When combining central nystagmus patterns and grade 2/3 GTI, sensitivity was increased to 76.4% [71.3-81.6%] and specificity to 90.3% [84.3-96.3%], however, no random effects model could be used. Sensitivity was higher in studies using the GTI rating (grade 2/3) by Lee (2006) compared to the approach by Moon (2009) (72.6% [67.4-77.2%] vs. 57.4% [49.5-64.9%], p=0.001).
Conclusions: In comparison to HINTS, the diagnostic accuracy of GTI is inferior. When combined with central nystagmus-patterns, diagnostic accuracy could be improved based on preliminary findings. GTI can be readily applied in the ED-setting and also in patients with acute imbalance syndrome.
Do people with unilateral hearing loss have an underlying vestibular dysfunction?
Jennifer Kelly1, Katherine Scigliano1, Maura Cosetti1, Brittani Morris2, Daphna Harel3, Anat Lubetzky2
1New York Eye and Ear Infirmary of Mount Sinai, New York, NY USA
2New York University, Department of Physical Therapy, New York, NY USA
3New York University, Department of Applied Statistics, Social Science and Humanities, New York, NY USA
Purpose: Recent studies suggest that hearing loss is associated with balance dysfunction and an increased risk of falls. The purpose of this study was to investigate whether adults with unilateral hearing loss (UHL) have an underlying vestibular dysfunction and whether vestibular testing relate to balance function.
Methods: We recruited 41 healthy controls (mean age 52, range 22-78) and 32 adults with stable UHL (mean age 52, range 18–80) who denied symptoms of dizziness (Dizziness Handicap Inventory average 2.28, range 0-14). UHL occurred an average of 8 years (range 4 months-64 years) prior to testing. We conducted the caloric portion of the Videonystagmography test, Video Head Impulse Test (vHIT) and a battery of functional balance tests: Standing on foam with eyes closed for 30 seconds, Timed-Up-and-Go, Four Square Step Test, 10-meter walk. Hearing was quantified by pure-tone-average (PTA). Caloric weakness was defined as asymmetry greater than 25%.
Results: Proportion of caloric weakness was higher in the UHL group (22%) than the control group (12%). Five participants with UHL refused caloric testing. There were no positive findings on the vHIT in either group. Participants with caloric weakness did not differ from those without caloric weakness in age or in any of the balance tests. The average severity of hearing loss in the impaired ear was 84.82 dB (SD=31.68) in the caloric weakness group vs. 69.75 dB (SD=24.5) in the normal caloric group.
Conclusions: Individuals with UHL are more likely to demonstrate caloric weakness than healthy controls, however, these findings are not correlated with functional changes.
Electroacoustic evaluation of the bone conduction transducer B250 in comparison with Radioear B71 and B81
Karl-Johan Fredén Jansson1, Bo Håkansson1, Ann-Charlotte Persson2, Luca Verrecchia3, Sabine Reinfeldt1
1Chalmers University of Technology, Department of Electrical Engineering, Gothenburg, Sweden
2Region Västra Götaland, Habilitation & Health, Hearing organization, Gothenburg, Sweden
3Karolinska Institutet, Dept of Clinical Science, Intervention and Technology, Stockholm, Sweden
Purpose: The B250 transducer was originally designed to generate high bone conduction (BC) sound at 250 Hz for efficient stimulation of the audio-vestibular system in clinical settings. The objective of this study is to evaluate its electroacoustic performance and to compare it with the two most widely used audiometric transducers B71 and B81.
Methods: A sample of six B250 prototype transducers were evaluated based on measurements of frequency response, total harmonic distortion (THD), maximum hearing level and electrical impedance. For comparison with B71 and B81, already published data from six samples of each device were analyzed together with complementary measurements of maximum hearing level at 125 Hz using seven samples of each device.
Results: The B250 has approximately 27 dB higher frequency response magnitude than both B71 and B81 at 250 Hz and can generate higher maximum hearing level than both devices at low frequencies: 11.8 to 35.8 dB (125-1000 Hz) higher than B71, and 1.4 to 18.6 dB (125-750 Hz) higher than B81.
Conclusions: The B250 produces higher output force with less distortion than both B71 and B81, especially at 125 and 250 Hz, which could possibly improve low frequency investigations of the audio-vestibular system.
Evaluating Vertical Semicircular Canal Function with Computerized Rotational Testing
Alexander Kiderman1, Fumihiro Mochizuki2, Erin Williams2, Michael Hoffer2
1Spryson America, Inc., Pittsburgh PA, USA
2University of Miami Miller School of Medicine, Department of Otolaryngology, Miami FL, USA
Purpose: The computerized rotational head impulse test (crHIT) employs whole-body impulsive rotations similar to the angular motion used in the video head impulse test (vHIT) to assess the function of all semicircular canals (SCCs). This study utilized vertical crHIT and vHIT among healthy subjects and participants with vestibular loss to evaluate the effectiveness of these tools in assessing SCC function.
Methods: Thirty-five individuals (15 males, 20 females; mean 25.9 ± 5.4 years [range: 21-51]) with no history of vestibular disorders or traumatic brain injury and 8 with vestibular hypo- or dysfunction (1 with bilateral vestibular dysfunction; 7 with unilateral vestibular dysfunction) were enrolled after providing written informed consent (#20190034). Participants underwent both vHIT testing (ICS Impulse Otometrics) and crHIT testing (Neuro-Otologic Testing Center, Spryson America, Inc.). Eye position was measured using a binocular infrared video-oculography system at a frame rate of 250 fps with sensors oriented in the pitch (x), roll (y), and yaw (z) planes. The Wilcoxon rank sum test was used to compare VOR gain values between groups.
Results: The gain of crHIT was significantly higher (p<0.05) than that of vHIT, except for the right horizontal SCC. The standard deviation of crHIT was smaller for all SCCs compared to vHIT. The error rate of crHIT in vertical SCC assessments was lower than that of vHIT. In patients with unilateral vestibular dysfunction, the gain of crHIT was lower than that observed in healthy subjects.
Conclusions: CrHIT can reliably evaluate the function of all SCCs, demonstrating its utility in both clinical and research settings.
Gain values of vestibulo-ocular reflex in video Head Impulse Test in children without otoneurologic symptoms
Rosana Rodriguez-Villalba1, Miguel Caballero Borrego2
1Althaia Xarxa Assistencial Universitària de Manresa
2Hospital Clínic de Barcelona
Purpose: This study aimed to explore the vestibulo-ocular reflex (VOR) with the video Head Impulse Test (vHIT) in healthy children at different development stages and to compare the values with the reference values in the adult population.
Methods: This prospective, single-center study recruited 187 children without otoneurological background or symptoms who were divided into three age groups (3-6, 7-10 and 11-16 years of age). The gain values were assessed using the video Head Impulse Test.
Results: Lower values of gain of the VOR were found in younger children when compared with the other age groups. There was not an increasing trend in gain values in children older than 7 years of age.
Conclusions: Gain values in the horizontal semicircular canals increase with age until children reach the 7-10 year-old group, when they match the normal values for adult population.
Gaps in Neuro-Vestibular Eye Movement Assessment by Clinical Neurologists in the AVERT Randomized Trial
Pouya B Bastani1, Ali Saber Tehrani1, Shervin Badihian2, John Carey3, David Zee1, David Newman-Toker1
1Johns Hopkins University School of Medicine, Department of Neurology, Baltimore, MD, United States
2Cleveland Clinic, Neurological Institute, Cleveland, OH, USA
3Johns Hopkins University School of Medicine, Department of Otolaryngology–Head and Neck Surgery, Baltimore, MD, United States
Purpose: Accurate assessment of eye movements is essential to diagnose the underlying cause of vertigo and dizziness. We examined the accuracy of neuro-vestibular exam documentation from the Acute Video-oculography for Vertigo in Emergency Rooms for Rapid Triage (AVERT) randomized trial.
Methods: Emergency department (ED) patients with acute vertigo/dizziness were eligible if video-oculography (VOG) or ataxia screening were abnormal. The gold standard was adjudicated interpretation of VOG recordings by two senior vestibular experts (one oto-neurologist, one neuro-otologist). A reviewer extracted components of the HINTS (head impulse, nystagmus, test of skew) and bedside positional tests from clinical neurology consultation notes. We report missing or mismatched findings relative to the gold standard using descriptive statistics. We defined mismatches as being those where differences could have impacted the final diagnosis.
Results: Neurology consultations were obtained in 53.1% (n=69/130). Complete documentation was infrequent (HINTS 28.9%, positional 4.3%) and complete, accurate documentation rare (HINTS 5.7%, positional 0.0%). Missing HINTS documentation included the head impulse test (HIT) in 49.2% (28.5% had abnormal HIT), nystagmus in 27.5% (57.8% had pathologic nystagmus), and test of skew in 62.3% (1.6% had skew present). Missing positional exam documentation (95.6%) included numerous cases where positional nystagmus was present by VOG (Dix-Hallpike 41.4%, supine roll 43.9%). We observed mismatched findings in 37.1% of HIT, 22% of nystagmus, 11.5% of skew, 35.7% of Dix-Hallpike, and 33.7% of supine roll exams documented by neurologists.
Conclusions: Current neuro-vestibular assessment in the ED, even by neurologists, is suboptimal. Diagnosis can likely be improved using standardized VOG.
HIMPS or SHIMPS – which test is better for children and when?
Angela Schell1, Ian Curthoys2, Valentin Held3, Nicole Rotter1, Lena Zaubitzer1
1Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Mannheim, Medical Faculty Mannheim, University of Heidelberg, Germany
2The University of Sydney, Vestibular Research Laboratory, School of Psychology, Sydney Australia
3Department of Neurology, University Hospital Mannheim, Medical Faculty Mannheim, University of Heidelberg, Germany
Purpose: While the HIMP protocol is well established in the diagnosis of vestibular disorders in children, the SHIMP protocol is less widely used. The aim of this study was to find out in which age group and in which situations one or the other test protocol is superior in terms of feasibility, reproducible results and test duration.
Methods: HIMP and SHIMP tests were performed in a total of 20 healthy children aged 9 months to 12 years. HIMP and SHIMP tests were administered to the horizontal semicircular canal with random and unpredictable 5-10 impulses per side. Outcome measures included VOR gains, occurrence of saccades, and side asymmetry. In addition, test duration was measured and children were asked which protocol they preferred.
Results: Reproducible results were obtained in all tests performed. In young children the SHIMP protocol was performed significantly faster than the HIMP protocol (p<0.05). VOR gains were within normal limits and no pathological saccades were observed in the HIMP protocol. Younger children (up to 9 years) preferred the SHIMP test.
Conclusions: The HIMP and SHIMP tests can be performed from 9 months of age and can be used as a screening test to detect impaired semicircular canal function. The SHIMP protocol seems to be more attractive in very young children, because it takes less time and is more popular with the children to be tested. Therefore, the SHIMP protocol should be considered as a useful alternative to the HIMP protocol.
Human Vestibular Compensatory Saccades are Affected by Flocculus Manipulation
Jacob Pogson1, Chris Song2, Nicholas Andresen3, Michael Schubert4, Andrew Bradshaw5, Miriam Welgampola5, David Zee6, Bryan Ward4
1Royal North Shore Hospital, Audiology, St Leonards, AUS
2The Johns Hopkins School of Medicine, Otolaryngology-Head & Neck Surgery, Baltimore, USA
3Johns Hopkins University School of Medicine, Baltimore, USA
4Johns Hopkins University School of Medicine, Otolaryngology-Head & Neck Surgery, Baltimore, USA
5Royal Prince Alfred Hospital, Neurology, Camperdown, AUS
6The Johns Hopkins School of Medicine, Neurology, Baltimore, USA
Purpose: Vestibular schwannomas (VS) are slow-growing benign tumors of the cerebellopontine angle (CPA). Surgical resection may be necessary for treatment and may occur through one of three approaches, including the retrosigmoid approach to the CPA. The retrosigmoid approach requires retraction and sometimes resection of the flocculus of the cerebellum. The flocculus is involved in oculomotor adaptation. We sought to examine the effects of ipsilateral flocculus manipulation for CPA surgery on the vestibulo-ocular reflex (VOR), compensatory saccades, functional gait dynamics, and clinical surveys.
Methods: We analysed data from 26 subjects who underwent VS resection via a retrosigmoid approach. All subjects then underwent an MRI less than 7 days post-surgery then vestibular and functional tests. As a proxy for flocculus manipulation, we calculated an MRI T2 intensity medulla–ipsilesional flocculus asymmetry-ratio (AR). We used linear mixed model regression to analyse the data.
Results: We found that for head impulses towards the ipsilesional canals, within the first month an increased MRI flocculus AR was associated with decreased compensatory saccade amplitudes yet at increased frequencies and latencies. Later, saccade metrics became similar to those with normal MRI AR. No other vestibular or saccade metric, functional gait, or survey showed a significant association with MRI AR.
Conclusions: We conclude that vestibular and or saccade adaptation after unilateral vestibular loss could be related to changes in flocculus intensity on MRI soon after CPA surgery. Head impulse compensatory saccade metrics could be used to monitor post-operative effects of surgery on the cerebellum.
Increased Directional Error in Anti-Saccade performance Measured by Saccadometry with Age
Michelle Petrak1, Chia-Cheng Lin2, Daniel Demian3, Liz Fuemmeler4
1Northwest Speech and Hearing, Chicago Ilinois, USA, Department of Vestibular Audiology
2East Carolina University, Greenville, North Carolina, USA, Department of Physical Therapy
3Venn Med, Toronto, Ontario, Canada, Department of Functional Neurology
4Professional Hearing Center, Kansas City, Missouri, USA Department of Vestibular Audiology
Purpose: Saccadometry is an ocular motor test battery that assesses the performance of saccadic movements. This test battery includes prosaccade (PS) and antisaccade (AS) tests, which gradually intensify cognitive demand. The aim of this study was to compare saccadometry performance between individuals aged 60-69 and 70-79 years old.
Methods: The Montreal Cognitive Assessment (MoCA) cognition test was performed on adults aged 70-79 years old. The saccadometry protocol was conducted using a head-mounted Video Oculography (VOG) eye-tracking goggle (Interacoustics®, Middelfart, Denmark). Latency, accuracy, velocity, directional error rate (DER), and overall performance error (OPR) rate were recorded during the PS and AS tests. Mann-Whitney tests were employed to compare the group differences in PS and AS performance, with a significance level set at α < .05.
Results: Group 1 included forty-seven healthy adults aged 60-69 years old (64 ± 3 years; 19M/28F) and Group 2 contained twenty-eight adults aged 70-79 years old (73 ± 3 years; 10M/18F). The statistical analysis showed that Group 2 significantly increased DER and OPR compared with Group 1 (DER: 37.21% vs. 13.3%; OPR: 51.61% vs. 21.13%, respectively) in the AS test. Group 2 also had slower saccade velocity compared with Group 1 (271 degrees/sec vs. 293 degrees/sec, respectively) in the PS test. The average MoCA score for Group 2 was 26 ± 3 out of 30.
Conclusions: Aging may affect the ability to correctly perform the AS test. However, cognitive function may not be associated with increased DER and OPR in adults aged 70-79 years old. Further study should investigate the effect of cognition on saccadometry performance in a clinical population.
International Pediatric Otolaryngology Group (IPOG) consensus on vestibular testing in children
Aurélie Coudert1, Jacob Brodsky2, Ingeborg Dhooge3, An Boudewyns4, Amanda Chiao5, Sharon Cushing6, Soumit Dasgupta7, Juan Manuel Espinosa Sanchez8, Joshua Gurberg9, Eugen Ionescu10, Carolyn Jenks11, Violette Lavender12, Audrey Maudoux13, Robert Oreilly14, Waheeda Pagarkar15, Marine Parodi16, Jeyasakthy Saniasiaya17, Fredrik Tjernstrom18, Sofia Waissbluth19, Josine Widdershoven20, François Simon21
1Hôpital Femme Mere Enfant, HCL, Lyon, France
2Boston Children's hospital, Boston, USA
3Ghent University Hospital, Ghent, Belgium
4Antwerp University Hospital, Antwerp, Belgium
5El Paso Children's Hospital, El Paso, USA
6Hospital For Sick Children, Toronto, Canada
7Alder Hey Children's NHS Foundation Trust, Liverpool, UK
8Hospital Universitario Virgen De Las Nieves, Granada, Spain
9Montreal Children's Hospital, McGill, Montreal, Canada
10Hôpital Edouard Herriot, Lyon, France
11Johns Hopkins School of Medicine, Baltimore, USA
12Cincinnati Children's Hospital, Cincinnati, USA
13Hôpital Robert Debré, Paris, France
14Children's Hospital of Philadelphia, Philadelphia, USA
15Great Ormond Street Hospital, London, UK
16Hôpital Necker-Enfants Malades, Paris, France
17University of Malaya, Kuala Lumpur, Malaysia
18Lund University, Lund, Sweden
19Pontificia Universidad Catolica De Chile, Santiago, Chili
20Maastricht University, Maastricht, Netherlands
21Hôpital Necker-Enfants Malades, Université Paris Cité, Paris, France
Purpose: Within the paediatric population, challenges and strategies can be very different depending on the age group and if the patient presents with vestibular symptoms or is being assessed for a cochlear implant. The objective of this study was to reach consensual guidelines on the minimal paediatric vestibular testing which should be performed in both expert referral centres and non-expert centres.
Methods: A modified Delphi process in three rounds was used to formally quantify consensus from opinion. During the first round, the 21 experts were invited to complete an online questionnaire focusing on all items that could be relevant for the consensus based on the literature and personal experience of the leadership group. Questions were asked for expert and non-expert paediatric vestibular clinics, respectively. A consensus was reached if more than 80% of participants agreed on a proposition.
Results: Consensus was obtained for three propositions. (i) For a non-expert team wishing to develop a paediatric vestibular consultation for any age, 17 respondents (81%) agreed that the minimal vestibular assessment should consist of lateral video Head Impulse Test (vHIT with remote camera) or rotatory chair, and cervical vestibular evoked myogenic potentials (VEMPs) in bone conduction. (ii) For an expert team for a 1-year-old child assessment 17 respondents (81%) agreed that minimal testing should include lateral vHIT and bone-conduction cervical VEMPs. (iii) For an expert team testing a 4-year-old child, 17 respondents (81%) agreed that the minimal testing should include vHIT in all canals, cervical VEMPs and ocular VEMPS in bone or air conduction, and rotary chair. Two propositions failed to reach consensus: (iv) the minimal vestibular assessment in a 8-year-old child, and (v) the use of caloric tests.
Conclusions: This international survey should help expert teams and non-expert teams perform more comparable vestibular tests in children, improving collaborations and setting minimal standards for new teams.
New vestibular neural responses to sound and vibration – clinical implications for VEMP testing
Ian Curthoys1, Christopher Pastras2
1University of Sydney, Australia
2Macquarie University, Australia
Purpose: The standard stimuli for clinical VEMP testing - air conducted sound (ACS) or bone conducted vibration (BCV) - activate vestibular primary neurons with irregular resting discharge, but also cochlear neurons. It is possible to record a purely vestibular evoked response (called the vCAP) in guinea pigs after complete ablation of the cochlea. How is the vCAP to ACS and BCV affected by manipulation of clinically important variables – stimulus rise time and masking
Methods: The vCAP to ACS or BCV is caused by synchronized action potentials of many individual irregular afferent neurons with calyx synaptic endings on type I receptors at the striola. It was recorded by an electrode close to the vestibular labyrinth, in response to transient ACS and BCV stimuli in anesthetized guinea pigs. Clicks, tone bursts and chirp stimuli were tested with and without masking.
Results: Lengthening stimulus rise-time degrades the vCAP, a result which parallels the decreased amplitude of human oVEMPs as rise time is increased. The vCAP is much more resistant to masking than is the cochlear compound action potential. On the basis of experiments with transmitter blockade we suggest the difference between auditory and vestibular responses is due to non-quantal transmission at the type 1- calyx synapse (effectively electrical resistive coupling) as the main generator of the vCAP.
Conclusions: To elicit the optimum clinical VEMPs, very short (even zero) rise times should be used. Masking differentially affects cochlear vs vestibular responses and is an important control in studies of vestibular evoked responses.
Objective assessment of gaze stabilization exercises in people with multiple sclerosis
Alia Alghwiri1, Faten Obeidat1, Zhihao Li2, Pedram Hovareshti2, Susan Whitney3
1University of Jordan
2BlueHalo
3University of Pittsburgh
Purpose: To assess gaze stability among people with multiple sclerosis (MS) by measuring objective metrics of Vestibular Ocular Reflex exercises (VORx1).
Methods: Forty three individuals with MS (21 with dizziness and 23 without dizziness) and 40 healthy controls were recruited. A tablet with VestAid investigational software (BlueHalo, US) was utilized to record gaze accuracy, head speed compliance, symptoms, and perceived difficulty of VORx1 trials. The VORx1 exercise is best described as the subject moving head in the yaw plane approximately 30° to the right and left from a target one meter in front of the persons face at the prescribed frequency (here, 80 per second) while keeping the non-moving target in focus. Subjects were exposed to 12 consecutive visual scenes (6 static and 6 optokinetic backgrounds). Results were analyzed using ANOVA, controlling for age, sex, and education level.
Results: Significant group effects were observed for the head speed compliance and perceived difficulty. For head speed compliances, healthy controls complied the best and persons with MS the worst (F (2, 850) = 32.19, p<0.001). For perceived difficulty, controls rated the task easier than the persons with MS (F (2, 850) = 73.23, p<0.001). Considering all subjects together, we also observed a significant (F (11, 850) = 7.55, p<0.001) effect of exercise condition on task difficulty ratings. Static backgrounds were perceived as easier than the optokinetic ones.
Conclusions: Preliminary analyses suggest that persons with MS show diminished head speed compliance in VOR exercises. Additional studies are required to determine if they compensate for better gaze stability by slowing their speed of head turn.
oVEMP oscillation: late peaks in healthy volunteers and patients with unilateral vestibular loss
Alyssa Dyball1, Xiao Ping Wu2, Belinda Kwok1, Chao Wang1, Benjamin Nham1, Jacob Pogson1, Jonathan Kong3, Rachael Taylor1, Konrad Weber4, Miriam Welgampola5, Sally Rosengren5
1Central Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
2Audiology Department, Macquarie University, Sydney, Australia
3Department of Otolaryngology, Royal Prince Alfred Hospital
4Departments of Neurology and Ophthalmology, University Hospital, Zurich
5Neurology Department and Institute of Clinical Neurosciences, Royal Prince Alfred Hospital, Camperdown, Australia
Purpose: The ocular vestibular evoked myogenic potential (oVEMP) is a measure of otolith function. The initial n10 peak follows a contralateral pathway from ipsilateral utricle to contralateral inferior oblique muscle. Following the n10, a series of positive and negative waves are elicited, but their characteristics and origin are unknown. This paper therefore investigated the latency, amplitude, and laterality of these late peaks in normal volunteers and patients with hearing or vestibular loss.
Methods: oVEMPs were elicited to bone-conducted (BC) square wave pulses and air conducted (AC) clicks in 63 healthy volunteers, 15 patients with profound hearing loss (HL), 45 patients with unilateral vestibular loss (uVL), and 3 patients with bilateral vestibular loss (bVL).
Results: All peaks were abolished in patients with bVL, and responses were similar to normal volunteers in patients with HL, confirming the vestibular origin of all peaks. In healthy volunteers, up to 5 peaks and troughs were elicited to BC bilaterally. The first two peaks were largest, and amplitude decreased linearly thereafter. In normal volunteers stimulated with AC clicks and patients with uVL stimulated with either stimulus, the first 2-3 oVEMP waves were larger on the side opposite the healthy/stimulated ear, while the later waves were smaller and had similar size bilaterally.
Conclusions: Like the clinical n10-p15 waves, the first several oVEMP waves follow a dominant contralateral pathway, while the later waves appear to have a separate origin and may represent bilateral projections to the extra-ocular muscles.
Self-rating of caloric-induced vestibular perception in common vestibular disorders
Filipp Filippopulos1, Doreen Huppert1, Sandra Becker-Bense1, Konstanze Dunker1, Bozidar Belanovic1, Nima Jooshani1, Ralf Strobl1, Andreas Zwergal2
1LMU University Hospital, German Center for Vertigo and Balance Disorders (DSGZ), Munich, Germany
2LMU University Hospital, German Center for Vertigo and Balance Disorders (DSGZ) & Department of Neurology, Munich, Germany
Purpose: Vestibular perception depends both on the intensity of the vestibular stimulus coded by inner ear sensors, and cognitive and emotional post-processing in higher vestibular networks. Clinical experience suggests differences in vestibular perception between common vestibular disorders. However, easy tools for its assessment and quantification are missing.
Methods: In this prospective study, 828 consecutive patients were recruited at the German Center for Vertigo and Balance Disorders (LMU Munich). All patients underwent routine caloric testing with warm (44°) and cold (30°) water for both ears. Slow phase velocity (SPV) of caloric-induced nystagmus was documented, respectively. Subjectively perceived vertigo sensation was rated by a numeric rating scale (NRS, 1-10), after each testing condition and in total. Mean NRS values and ratios of NRS per caloric-induced SPV were calculated for patient subgroups with different vestibular disorders (defined by established diagnostic criteria).
Results: NRS showed a good correlation with the mean caloric-induced SPV across all patients. NRS values significantly decreased with age even after controlling for gender, caloric-induced SPV, vHIT gain, and diagnosis. Women had higher NRS values than men. Patients with functional dizziness and vestibular migraine had the highest NRS values, while patients with bilateral vestibulopathy had the lowest. A NRS-threshold of ≥7 had a ROC-AUC of 0.67 for functional dizziness, a NRS-threshold of ≤4 a ROC-AUC of 0.77 for bilateral vestibulopathy. Ratios of NRS per mean caloric-induced SPV were highest for patients with bilateral and unilateral vestibulopathy.
Conclusions: Subjective rating of vertigo sensation induced by a standardized caloric stimulus is a clinically suitable estimate of vestibular perception and can support differential diagnosis in common vestibular disorders. Central vestibular perception decreases with age and increases with female gender.
The sacculo-ocular reflex in normal and vestibularly damaged subjects
Fitim Fetahu1, Adolfo Bronstein1, Melis Kaçan1
1Neuro-otology Unit, Department of Brain Sciences, Imperial College London, Charing Cross Hospital, London, UK
Purpose: Cervical_VEMPs are considered to test saccular function but, because delivering linear acceleration along the longitudinal axis of the body is challenging, cVEMP results have never been correlated with other saccular tests. Here we present a sacculo-ocular test in normal and vestibular-damaged subjects and correlate these data with cVEMPs and other audio-vestibular tests.
Methods: Subjects sat on a “bouncy chair” fitted with a heavy-duty spring, propelled into its natural motion frequency by an experimenter pressing manually onto the subjects’ shoulders. This resulted in regular sinusoidal motion at a frequency of 1.80Hz. Dynamic visual-acuity (DVA) was measured by subjects identifying numbers flashing every second on a LED visual display, and dividing the results by visual-acuity whilst stationary. Large, medium and small font sizes were used to fine-tune visual performance. Subjects tested included: 37 normal subjects; 18 patients with unilateral canal-paresis, 9 patients with bilateral vestibular loss and 14 dizzy patients with normal vestibular results.
Results: Normal subjects had a negligible drop in DVA with the smaller font only. In bilateral vestibular loss patients DVA dropped by circa 50%, more severely with smaller fonts. Patients with severe unilateral canal paresis >40% often reported oscillospia and their DVA dropped by circa 50%, worse with smaller fonts. Patients with mild canal paresis <40% did not report oscillopsia and, in agreement, DVA only dropped by 15-20% during motion. Grouping all 41 patients together, correlations (Pearson “r”) between DVA and caloric tests were r=0.589, with cVEMP r=0.133 and with horizontal vHIT r=0.354.
Conclusions: This simple test of saccular-ocular function reflects both the amount of vestibular loss and the presence of oscillopsia in vestibular patients. The dynamic visual acuity findings correlate reasonably well with established vestibular tests such as caloric test but not specially highly with cVEMP results. Hence these data challenge the view that cVEMPs represent a specific saccular test.
The value of scales and patient reported outcome measures (PROMs) in neuro-otology
Alexander Andrea Tarnutzer
1
1Cantonal Hospital of Baden, Baden, Switzerland and Faculty of Medicine, University of Zurich, Zurich, Switzerland
Purpose: Essential to the success of clinical trials are reliable and universally applicable outcome measures. While state-of-the-art objective measures in neuro-otology are now broadly available, scales and patient-related measures are still not yet the norm in the field, presenting a significant limitation to clinical trial preparedness. Here the current role of scales and patient reported outcome measures (PROMs) in neuro-otology is reviewed.
Methods: Review of established and emerging scales and PROMs that have been used in the field of neuro-otology, focusing both on peripheral- and central-vestibular disorders including ataxia. Strengths and limitations are summarized.
Results: A broad range of rating scales designed for patients experiencing dizziness, with an emphasis on subjective rating scales, including the Dizziness Handicap Inventory (DHI), ABC Scale, and the eye movement and vestibular components of well-known cerebellar rating scales such as the International Cooperative Ataxia Rating Scale (ICARS), Brief Ataxia Rating Scale (BARS), and Scale for Assessment and Rating of Ataxia (SARA) was identified and will be reviewed. The strengths and weaknesses of the latest addition, the Scale of Ocular Motor Disorders in Ataxia (SODA), will also be discussed.
Conclusions: Several PROMs and scales have reached substantial attention and are frequently used (including DHI and SARA). The recently developed SODA scale also addresses oculomotor deficits in ataxia. However, there is a lack of more targeted PROMs within neuro-otology, e.g. for reported oculomotor or vestibular deficits, emphasizing the need to develop such PROMs in the future.
The vestibular system in children with neurodevelopmental disorders: a neglected sense?
Ruth Van Hecke1, Frederik J.A. Deconinck2, Emmely Van Acker1, Maya Danneels1, Ingeborg Dhooge3, Hilde Van Waelvelde1, Jan R. Wiersema4, Leen Maes5
1Ghent University, Department of Rehabilitation Sciences, Belgium
2Ghent University, Department of Movement and Sports Sciences, Belgium
3Ghent University (Hospital), Department of Otorhinolaryngology/Department of Head and Skin, Belgium
4Ghent University, Department of Experimental Clinical and Health Psychology, Belgium
5Ghent University (Hospital), Department of Otorhinolaryngology/Department of Rehabilitation Sciences, Belgium
Purpose: Despite similarities in symptoms found in children with neurodevelopmental disorders (NDDs) and those with vestibular impairments, a thorough investigation of the vestibular system in children with an NDD is lacking. Therefore, the aim of the current study was to explore the integrity of the peripheral vestibular organ in this population and to investigate to what extent motor competence in children with NDDs may be related to the function of the vestibular system.
Methods: Twenty-eight participants with a neurodevelopmental disorder (NDD) (6 girls, 22 boys; 6-13 years; 9.3±2.4 years) were enrolled in this pilot study. Sixteen participants were diagnosed with a single NDD (ASD: n=7, DCD: n=3; ADHD: n=6), while comorbidity of at least one other NDD was present in the remaining 12. The integrity of the peripheral vestibular system was evaluated using ocular and cervical vestibular evoked potentials (o/cVEMP), and a video head impulse test (vHIT); motor competence with the Movement Assessment Battery for Children (M ABC), 2ndversion and Körperkoordinationtest für Kinder (KTK). Results were compared to an age and sex-matched control group (9(7) ± 1(9) years).
Results: Compared with the control group, the NDD group had on average significantly higher interpeak amplitudes on c/oVEMP. No group differences were found on the vHIT, however, pathological correction saccades were noted for the right horizontal semicircular canal in one child of the NDD-group. Overall, compared to normative data (n = 140; 9.5 ± 2.0 years; 6 – 13 years), abnormal otolith function was seen in eleven children with NDDs (39%). A moderate positive correlation was found between the cVEMP amplitude and the score on the M ABC 2.
Conclusions: Although the relatively small sample warrants caution with interpreting the results, these findings seem to suggest the vestibular system may be involved in the phenotype of at least a proportion of children with DCD, ASD, and/or ADHD.
Validation of a bone-conducted oVEMP protocol with stimulation at Fz by the B250 transducer
Zheer Tawfique1, Magnus Westin1, Sabine Reinfeldt2, Karl-Johan Fredén Jansson2, Laura Fröhlich3, Julia Dlugaiczyk4, Leigh McGarvie5, Ian Curthoys6, Bo Håkansson2, Luca Verrecchia1
1ENT Audiology and Neurotology Department, Karolinska University Hospital, Stockholm, Sweden
2Division of Signal Processing and Biomedical Engineering, Chalmers University of Technology, Gothenburg, Sweden
3Department of Otorhinolaryngology, University Hospital Bonn, Bonn, Germany
4Department of Otorhinolaryngology, Head and Neck Surgery & Interdisciplinary Center of Vertigo, Balance and Ocular Motor Disorders, University Hospital Zurich, University of Zurich, Switzerland
5Neurology Department, Institute of Clinical Neurosciences, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
6Vestibular Research Laboratory, School of Psychology, Faculty of Science, University of Sydney, Sydney, NSW, Australia
Purpose: The clinical need of a more user-friendly bone conduction (BC) transducer for VEMP testing has resulted in the development of the B250 prototype by the Biomedical Signals and Systems Research Group at Chalmers University of Technology, Sweden. The main features of the B250 are its compact design, compatibility with most commercial devices and its ability to deliver BC stimuli at high intensity with negligible distortion at low frequencies, with peak performance at 250 Hz. The golden standard for BC VEMP is the Minishaker B&K 4810 (MS). However, its size, price and operator specificity have limited its clinical use. The B250 thus seems a valid alternative to the MS.
Here, we present the preliminary results of an ongoing validation study of bilateral simultaneous BC oVEMP evoked by B250 at Fz (10-20 system).
Methods: Data has so far been collected from 6 healthy subjects, age and sex matched. They underwent bilateral simultaneous BC oVEMP recording, evoked by both MS and B250. Stimulation was a single cycle 250 Hz stimulus delivered at Fz with 135 dB peFL intensity. Each subject was stimulated with both transducers, with the same electrode montage, with two alternative stimulus polarities and test-retest repetition.
Results: So far, the B250 shows robust and reproducible results, similarly to MS in terms of amplitude. Latencies change according to stimulus polarity, however the B250 showed an unexpected delay of 2,8 ms when condensation stimulus was used. This delay may be related to the observed initial mechanical inertia of the B250 for transient stimuli.
Conclusions: The B250 seems a valid alternative to the MS in clinical BC oVEMP testing.
Vestibular Function and Complaints in Patients with Untreated Unilateral Vestibular Schwannoma
Constanza Fuentealba Bassaletti1, Babette van Esch2, Kenny van Liesbout3, Heiko Locher2, Jeroen Jansen2, Radboud Koot2, Peter Paul van Benthem2, Erik Hensen2
1Leiden University/ Leiden University Medical Center, Department of Otorhinolaryngology / Head and Neck Surgery, The Netherlands. Apeldoorn Dizziness Centre/ Gelre Hospitals, The Netherlands
2Leiden University/ Leiden University Medical Center, Department of Otorhinolaryngology / Head and Neck Surgery, The Netherlands
3Leiden University/ Institute of Education and Child Studies, The Netherlands
Purpose: The primary aim of this study is to assess the vestibular function of patients with unilateral vestibular schwannoma and correlate their outcome to vestibular complaints and quality of life. Secondly, we evaluated patient and tumor characteristics that may affect these outcomes.
Methods: In this cross-sectional study, patients with unilateral vestibular schwannoma aged ≥18 years were included. The participants were evaluated with caloric test, vHIT, cVEMP, DHI, PANQOL and SF-36. Tumor and patient characteristics were retrieved from the patient file. Linear regression analyses were performed to identify predicators for vestibular function.
Results: The majority (89%) of vestibular schwannoma patients showed one or more objective vestibular abnormalities. The horizontal and anterior vHIT correlated with the caloric test results, and vHIT outcomes were correlated with hearing loss (lower gain is associated with worse hearing [p<0.05]) and tumor size (lower gain is associated with bigger tumors [p= 0.005]). However, there was no significant correlation between the objective vestibular test results and vestibular complaints or quality of life. Likewise, tumor characteristics did not correlate with subjective outcomes. Even so, DHI scores showed a strong inverse correlation with PANQOL scores (p<0.001).
Conclusions: Vestibular complaints have a significant impact on the quality of life in vestibular schwannoma patients. Whereas v-HIT does correlate with tumor size and hearing loss, objective vestibular function tests nor tumor characteristics correlate well with vestibular complaints or quality of life in this patient group.
Vestibular function tests separates stroke and vestibular neuritis accurately in the emergency department
Nicole Reid1, Benjamin Nham2, Chao Wang1, Nicole Reid1, Belinda YC Kwok3, Deborah A Black4, Andrew Bradshaw1, G Michael Halmagyi1, Miriam S Welgampola1
1Institute of Clinical Neurosciences, Royal Prince Alfred Hospital, Sydney, Australia
2St George and Sutherland Clinical School, University of New South Wales, Sydney, Australia
3Central Clinical School, University of Sydney, Sydney, Australia
4Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
Purpose: Clinical assessment of the acutely vertiginous patient presenting to emergency-department is superior to neuroimaging in separating posterior-circulation stroke (PCS) and vestibular-neuritis (VN) but remains challenging for the clinician. However, clinical bedside head-impulse-nystagmus-and-test-of-skew (HINTS) test is imperfect in achieving this. This study sought to assess whether quantitative vestibular tests could help separate PCS and VN.
Methods: Patients were prospectively recruited from the emergency-department within 72 hours of presentation. Video-nystagmography (VNG), three-dimensional video head-impulses testing (vHIT), vestibular-evoked myogenic potentials (VEMPs) and subjective visual-horizontal (SVH) were performed.
Results: There were 128 PCS and 134 VN patients. Common stroke-territories were: posterior-inferior-cerebellar-artery, basilar-perforators, multi-territory and anterior-inferior-cerebellar-artery (41.4%, 21.1%, 14.1%, 7.8%). Most VN and stroke patients presented with acute vestibular syndrome (96.6%, 61.7%).
In PCS, absent-nystagmus (53.9%), horizontal (32%) or vertical/torsional (14.1%) nystagmus was recorded whilst in VN, horizontal (98.5%) or vertical/torsional spontaneous-nystagmus (1.5%) was recorded. Ipsilesional horizontal-canal (HC) vHIT-gain was lower in VN than in PCS (0.47±0.24, 0.92±0.20, p<0.001). Ipsilesional SVH deviation >2.5○occurred more often in VN than in PCS (97.6% and 24.3%, p<0.01). Abnormal bone-conducted ocular-VEMP (oVEMP) asymmetry-ratio was more common in VN than PCS (50% and 14.4%, p<0.01).
Using the ten best discriminators (VNG, vHIT, SVH and oVEMP metrics), VN was separated from PCS with a sensitivity of 92.9% and specificity of 89.8%. Adding VNG and vHIT to the HINTS test enhanced sensitivity and specificity from 95.3% and 63.4% to 96.5% and 80.6%.
Conclusions: Quantitative vestibular testing helps separate PCS from VN and could improve diagnostic accuracy in the emergency-department.
Vestibular Paroxysmia: ictal nystagmus and Audiovestibular Test profiles
Miranda Morrison1, Belinda Kwok1, Nicholas Yang1, Rachael Taylor2, Miriam Welgampola1
1Institute of Clinical Neurosciences Royal Prince Alfred Hospital, University of Sydney Australia.
2Department of Physiology, University of Auckland, Auckland, New Zealand;
Purpose: To characterize ictal nystagmus and audiovestibular test results in ten patients diagnosed with vestibular paroxysmia by Barany Society Criteria
Methods: All patients underwent interictal video nystagmography, three-dimensional video head-impulse testing, cervical and ocular VEMPs to air and bone-conducted sound. Ictal nystagmus was captured in eight patients.
Results: Eight patients reported brief spells of spinning vertigo lasting 30s or less; two reported symptoms lasting minutes. Two had additional positional dizziness, four had monaural tinnitus time locked with vertigo. Ictal nystagmus was documented at the bedside in 2 patients, recorded on home video oculography in 5 and on a smartphone by one patient. Five demonstrated ipsiversive horizontal or torsional spontaneous nystagmus one demonstrated ipsiversive followed by contraversive horizontal nystagmus. Two patients demonstrated right-beating nystagmus, in the absence of audiovestibular loss. Six patients demonstrated ipsilateral horizontal canal dysfunction on vHIT, with gains ranging from 0.38-0.7. Three had cVEMP asymmetry (50-100% asymmetry ratios) and two had asymmetric hearing loss.
Paroxysmia was attributed to neurovascular compression by AICA loops (n=4) or an ectatic vertebral artery (n=1); and other structural causes in four (sarcoidosis, CPA meningioma, CPA lipoma and church-Strauss syndrome). Six patients received carbamazepine as first-line treatment. Two switched to cinnarizine and 2 to oxcarbazepine due to intolerance. Three underwent microvascular decompression, with symptom resolution.
Conclusions: unilateral audio-vestibular dysfunction and irritative nystagmus are observed in vestibular paroxysmia and may assist diagnosis.
Video ocular counter roll (vOCR): A bedside test of otolith-ocular function
Amir Kheradmand
1
1Departments of Neurology, Neuroscience, Otolaryngology–Head & Neck Surgery, and Laboratory for Computational Sensing and Robotics (LCSR)
Purpose: This is a request for a 30-45min talk to provide a synopsis on the video ocular counter roll (vOCR), the new clinical test of otolith ocular function, and review the work done on its validation and diagnostic value.1-4
1. Otero-Millan J, Roberts DC, Lasker A, Zee DS, Kheradmand A. Knowing what the brain is seeing in three dimensions: A novel, noninvasive, sensitive, accurate, and low-noise technique for measuring ocular torsion. J Vis. 2015;15(14):11
2. Otero-Millan J, Treviño C, Winnick A, Zee DS, Carey JP, Kheradmand A. The video ocular counter-roll (vOCR): a clinical test to detect loss of otolith-ocular function. Acta Otolaryngol. 2017;137:593–597.
3. Sadeghpour S, Fornasari F, Otero-Millan J, Carey JP, Zee DS, Kheradmand A. Evaluation of the Video Ocular Counter-Roll (vOCR) as a New Clinical Test of Otolith Function in Peripheral Vestibulopathy. JAMA Otolaryngology–Head & Neck Surgery. 2021;147:518-525.
4. Yang Y, Tian J, Otero-Millan J, Kheradmand A. Video ocular counter roll: A bedside test of otolith-ocular function. Annals of Clinical and Translational Neurology. 2023;10:2426-2429.
Methods: The vOCR test is based on measurement of torsional vestibulo-ocular reflex with a lateral head tilt using video-oculography. It consists of a simple maneuver during which the head and torso are tilted en bloc by the examiner.
Results: The pattern of vOCR deficit among patients highlights its clinical value in identifying the stage of vestibular loss and recovery.
Conclusions: The quick application of vOCR allows examination of otolith-ocular function and assessment of vestibular recovery at the bedside.
10. Functional and Psychiatric Vestibular Disorders
Allocentric Navigation Impairment in Functional Dizziness: Virtual Reality Insights into Independent Mechanisms
Hayo Breinbauer1, Camilo Arevalo-Romero1, Karen Villarroel1, Felipe Faundez1, Claudio Lavin2, Pablo Billeke2, Paul Delano3
1Laboratory for Clinical Neuro-Otology and Balance-Neuroscience,University of Chile, Neuroscience Department, Chile
2Laboratorio de Neurociencia Social y Neuromodulación, Centro de Investigación en Complejidad Social (neuroCICS), Facultad de Gobierno, Universidad del Desarrollo, Chile
3Servicio de Otorrinolaringología, Hospital Clínico Universidad de Chile, Chile
Purpose: To explore spatial cognition mechanisms in Persistent Postural Perceptual Dizziness (PPPD) by evaluating spatial navigation performance and associated sensory behaviors in both non-immersive and virtual reality (VR) environments.
Methods: We employed a virtual Morris Water Maze (vMWM) test with both a standard monitor and a VR headset to assess 19 PPPD patients, 20 non-PPPD patients with similar vestibular disorders—including vestibular migraine (VM)—and 12 healthy volunteers. We incorporated eye-tracking, head kinematics, and psycho-cognitive assessments to enhance our spatial navigation evaluation.
Results: Non-PPPD vestibular patients displayed significantly inferior spatial navigation skills compared to healthy volunteers, with PPPD patients performing markedly worse than both groups. PPPD patients demonstrated a reduced tolerance to VR, completing fewer vMWM trials than their non-PPPD counterparts. VM patients also showed some VR intolerance, albeit less severe than those with PPPD. No notable differences in spatial navigation performance between VR and non-immersive settings were found in patients who tolerated VR. Analysis of gaze behavior indicated that PPPD patients relied more heavily on visual cues than control groups. In VR settings, all patients with vestibular disorders exhibited less head movement than healthy volunteers, yet PPPD patients showed more head movement than non-PPPD vestibular patients.
Conclusions: Both VM and particularly PPPD affect visuo-spatial processing and VR tolerance. Our findings suggest that PPPD patients exhibit unique compensatory behaviors, such as increased reliance on visual cues and head movements for navigation, possibly reflecting a distinct and underlying mechanism affecting allocentric navigation strategies that is independent of visuo-vestibular processing.
Long-term prognosis in patients with Persistent Postural-Perceptual Dizziness (PPPD)
Jan Erik Berge1, Frederik Kragerud Goplen1, Stein Helge Glad Nordahl2, Mari Kalland Knapstad1
1Department of Otorhinolaryngology & Head and Neck Surgery, Haukeland University Hospital, Bergen, Norway
2Department of Clinical Medicine, University of Bergen, Bergen, Norway
Purpose: Persistent Postural-Perceptual Dizziness (PPPD) is a recently defined vestibular diagnosis with current diagnostic criteria published in 2017. There is therefore a lack studies on long-term prognosis for these patients.
Methods: We included 135 adult participants referred to an otolaryngology department for suspected vestibular disease with 3 years observational period. All patients underwent posturography, videonystagmography and clinical examination. Treatment included information from physical therapist at baseline, recommendations on further therapy and recommendations for medical treatment if appropriate. Dizziness Handicap Inventory (DHI) was reported at baseline and after 3 years and total-score was used for statistical analyses. Student t-test was used to compare continuous variables and linear regression analyses were used to compare differences between groups with adjustment for age and gender.
Results: 18 patients were diagnosed with PPPD. Preliminary results shows that PPPD-patients have a higher DHI-score at baseline 55.3 (SD 16.3) versus 30.2 (SD 21.6) in patients without PPPD p-value <0.001. Linear regression with adjustment for age and sex estimated this difference to Coeff 25.0 (95% CI 14.3-35.7). After three years there was no significant difference in DHI-score between patients with and without PPPD mean 28.1 (SD 27.3) vs 20.1 (SD 22.0) p=0.20, after adjusting for age and sex Coeff 9.8 (95% CI -1.3, 20.9) this difference was still not significant.
Conclusions: Patients with PPPD undergoing clinical examination and brief counselling by trained physiotherapists and otolaryngologist at baseline with individualized recommendations for further follow-up by primary care health-care professionals do experience improvement that persists for 3 years.
Persistent postural-perceptual dizziness (PPPD) is associated with obstructive sleep apnea
Anand Bery1, Jayson Azzi2, Andre Le3, Naomi Spitale4, Judith Leech5, Daniel Lelli6, Darren Tse3
1The Johns Hopkins Hospital, Department of Neurology, Baltimore, MD, United States
2Department of Otolaryngology - Head & Neck Surgery, University of Manitoba, Winnipeg, MB, Canada
3Department of Otolaryngology - Head & Neck Surgery, University of Ottawa, Ottawa, ON, Canada
4Royal Ottawa Mental Health Centre, and Department of Medicine, Division of Respirology, Ottawa, ON, Canada
5Department of Medicine, Division of Respirology, University of Ottawa, Ottawa, ON, Canada
6Department of Medicine, Division of Neurology, University of Ottawa, Ottawa, ON, Canada
Purpose: Obstructive sleep apnea (OSA) has been linked to vestibular dysfunction, but no prior studies have investigated the relationship between Persistent Postural-Perceptual Dizziness (PPPD), a common cause of chronic dizziness, and OSA.
Methods: We determined the frequency of OSA in an uncontrolled group of PPPD patients from a tertiary dizziness clinic based on polysomnogram (PSG). We then assessed the sensitivity and specificity of common OSA questionnaires in this population.
Results: Twenty-five patients with PPPD underwent PSG (mean age 47, 60% female, mean BMI 29.5). A majority, or 56%, of patients were diagnosed with OSA, and in most, the OSA was severe. OSA patients were older (56 years versus 40 years, p = 0.0006) and had higher BMI (32 versus 26, p = 0.0078), but there was no clear gender bias (56% versus 64% female, p = 1.00). The mean sensitivity and specificity of the STOP BANG questionnaire for detecting OSA was 86% and 55%, respectively. Sensitivity and specificity of the Berlin Questionnaire was 79% and 45%, respectively.
Conclusions: The prevalence of OSA was much higher in our small PPPD group than in the general population. Screening questionnaires appear to demonstrate good sensitivity to detect PPPD patients at risk of OSA in this small study. Future studies should confirm these findings and determine whether treatment of OSA improves symptoms in PPPD.
Psychological impact of having a vestibular disease - preliminary data from a Tertiary Danish University Hospital
Dan Dupont Hougaard1, Regitze Kuhr Skals2, Laura Petrini3
1Aalborg University Hospital, Balance & Dizziness Centre, Department of Otorhinolaryngology, Head & Neck Surgery and Audiology, Aalborg, Denmark
2Aalborg University Hospital, Unit of Epidemiology and Biostatistics, Aalborg, Denmark
3Aalborg University, Department of Health Science and Technology, Center for Neuroplasticity and Pain, Aalborg, Denmark
Purpose: Dizziness is a very common complaint and etiologies are numerous. Almost 50 percent of all dizziness relates to the inner ear disease. The natural cause of these inner ear diseases vary quite a lot, especially when it comes to duration. Often subjects, who do not fully recover from their vestibular deficit, experience psychological issues that may worsen their vertiginous symptoms. These psychological issues are often overlooked or even misinterpreted. The primary aim of this study was to determine the prevalence of psychological issues in relation to vestibular disease. Secondary aim was to determine the prevalence of psychological issues in relation to specific vestibular diseases. Tertiary aims included determination of any correlation between the severity of questionnaire scores and different subject characteristics (specific vestibular diseases, age, gender, duration of symptoms).
Methods: Approximately 300 subjects will be eligible for inclusion for this study at the time of presentation. All patients must fill out the 25-item Dizziness Handicap Inventory-, The Depression, Anxiety and Stress Scale 21 (DASS-21)-, and The Brief Illness Perception Questionnaire (BIPQ) questionnaires.
Results: Data covering all aims will be presented. Prevalences and correlation analyses of questionnaire scores in relation to gender, age, diagnoses, and duration of dizziness will be presented.
Conclusions: The prevalence of phycological issues in patients suffering from a vestibular disease will be determined. Based upon our results, recommendations will be made on 1) where to look for psychological issues (subgroups and characteristics) and 2) how to identify psychological issues in patients suffering from vestibular disease.
Psychosocial Factors are Associated with Life Space and Disability in Persons with Dizziness
Pamela Dunlap1, Patrick Sparto1, Jeffrey Staab2, Joseph Furman3, Susan Whitney1
1University of Pittsburgh, Department of Physical Therapy, Pittsburgh, PA, USA
2Departments of Psychiatry and Psychology and Otolaryngology Head and Neck Surgery, Rochester, MN, USA
3University of Pittsburgh, Department of Otolaryngology, Pittsburgh, PA, USA
Purpose: This study aimed to assess the association between psychosocial factors with functional and community mobility as well as future disability outcomes among persons with dizziness.
Methods: A prospective cohort study was conducted with a baseline and 3-month follow-up assessment. Psychosocial factors were measured at baseline using the Hospital Anxiety and Depression Scale (HADS), the Patient Health Questionnaire 4-item (PHQ-4), the Vestibular Activities Avoidance Instrument (VAAI), and the Dizziness Catastrophizing Scale (DCS). Mobility was assessed at baseline using the Five Times Sit to Stand (5xSTS) Test, usual pace gait speed, and the Life Space Assessment (LSA). Disability measures at 3-months included the Dizziness Handicap Inventory (DHI), Activities-specific Balance Confidence Scale (ABC), and Vestibular Activities and Participation Measure (VAP). We used Spearman’s correlation coefficient to determine the associations between psychosocial factors and mobility/disability measures.
Results: The study included 100 participants at baseline (mean age (SD)=49.2 (15.7); 73% female) with 68 participants completing the 3-month follow-up. Negative associations were found between gait speed and VAAI (p=-0.21, p=.04) and HADS-D (p=-0.21, p=.03) at baseline. The LSA was negatively associated with all psychosocial factors except PHQ-A at baseline (p<.05). Baseline HADS-A was associated with 3-month DHI (p=0.26, p=.03), and baseline HADS-D and PHQ-D scores were associated with all measures of community mobility and disability at 3 months (p<.05). Baseline DCS was associated with 3-month VAP score (p=0.27, p=.03) and DHI score (p=0.33, p<.001). Baseline VAAI score was associated with 3-month VAP score (p=0.58, p<.001), DHI score (p=0.65, p<.001), and ABC score (p=-0.55, p<.001).
Conclusions: We found that anxiety and depressive symptoms and dizziness-related catastrophic beliefs and behaviors: (1) adversely affected gait speed and mobility in daily life activities, and (2) portended greater disability and poorer community mobility at 3-month follow up. Individuals with dizziness-related psychological morbidity are at risk for reduced activity and participation following vestibular dysfunction.
The role of expectation in the cortical processing of vestibular input
Toby Ellmers1, Sanya Srivastava1, Adolfo Bronstein1
1Imperial College London, Department of Brain Sciences, UK
Purpose: It is important that humans are able to discriminate between unpredictable vestibular stimuli and that which is self-triggered and thus expected. Such discrimination is crucial for ensuring that appropriate vestibular reflexes are triggered to maintain postural stability (e.g., triggering a reflexive action when head movement occurs during slipping/tripping but not when looking up at the sky). Disruptions in such discriminative ability have been hypothesised to underpin higher-level disorders of 'functional dizziness', whereby dizziness occurs without any apparent peripheral vestibular dysfunction. Despite this, little is known about how expectation affects higher-level cortical processing of vestibular input in humans, and if such discrimination (and thus disruption to) occurs at the level of the cortex.
Methods: Here, we recorded EEG from 22 healthy young adults undergoing discrete whole body yaw rotations. During one condition ('Unexpected'), rotations were unexpected with respect to timing, direction and speed. During another condition ('Expected'), rotations were predictable in terms of direction and speed, and were self-triggered by the participants themselves.
Results: During ‘Expected’ rotations, there was a significant increase in pre-rotation oscillatory beta power (a marker of reduced sensory sensitivity). This increase was restricted to the parietal cortex: an area of the brain known to process vestibular input. Expectation also abolished the initial post-rotation theta activation (a likely sensory ‘error signal’). We also observed significantly increased inter-site phase clustering between the pre-frontal and parietal cortex during Expected rotations.
Conclusions: Overall, these findings reveal that humans can cortically down-weight the processing of expected (and self-triggered) vestibular input. Ongoing work is exploring how these results directly influence vestibular perception, and how these processes may be disrupted in functional dizziness disorders.
Vortioxetine for the patients with PPPD and depression
Kensuke Kiyomizu1, Takeshi Nakamura2, Kuniyuki Takahashi3, Hideki Funahashi4
1a. Department of Otorhinolaryngology and Psychiatry, Yoshida Hospital, Nobeoka, Japan. b. Department of Otorhinolaryngology, Head & Neck Surgery, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
2Department of Otorhinolaryngology, Head & Neck Surgery, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan, 8891692
3Department of Otorhinolaryngology, Head & Neck Surgery, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
4Department of Clinical Neuroscience, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
Purpose: PPPD is a new chronic dizziness disease that has been introduced by the Barany Society. Vortioxetine (Trinterix) is a new antidepressant (S-RIM: Serotonin Reuptake Inhibitor and Modulator) with less side effects and effective well. We therefore investigated the effectiveness of vortioxetine therapy for the patients with MD and PPPD with depression.
Methods: Out of 1518 patients (503 men, 1015 women) (mean age, 60.5 years) with dizziness. PPPD was revealed in 259 patients (17.1%) (78 men, 181 women, (mean age, 58.4 years). By the way, vortioxetine treatment performed 116 all depressive patients (with or without dizziness) (49 men, 67 women) and PPPD was revealed in 66 patients, of which 33 patients (average age 56.5 years) could be compared before and after therapy.
Results: Psychiatric comorbidity was revealed in 75.9% (265/349) with MD. Psychiatric comorbidity was revealed in 93.4% (242/259) with PPPD. This number was extremely high compared to 71.5% (1086/1518) of all dizziness diseases. The prevalence of comorbid mood disorders was high at 30.9% (75/242). DHI scores were improved (60.1→42.1→31.6, before→1M→2M:). In VOR tests, DP% scores (vestibular function) were improved (16.77→6.808) in 12 cases.
Conclusions: We reported the possibility that sertraline (SSRI) acts directly on the vestibular nervous system. These results of the present clinical research suggested that vortioxetine (S-RIM) might have some effects which improved the vestibular function in patients with dizziness and depression as well as sertraline (SSRI). It was expected that dizziness symptoms would improve by reducing anxiety. In order to reduce the side effects, it’s important to start with a lower first dose of like 0.25-0.5T (1T=10mg), gradually increase the dose like 1-2T, and continue for a long period of time (about 3-6M) until a sufficient effect is obtained.
11. Gait, Posture, and Locomotion
Altered postural control in aging is marked by systemic muscle co-contraction
Scott Mongold1, Christian Georgiev1, Esranur Yildiran Carlak1, Antonella Iannotta1, Gilles Naeije2, Marc Vander Ghinst3, Mathieu Bourguignon1
1Laboratory of Neurophysiology and Movement Biomechanics, UNI - ULB Neuroscience Institute, Université libre de Bruxelles, Brussels, Belgium
2Laboratoire de Neuroanatomie et Neuroimagerie translationnelles, UNI – ULB Neuroscience Institute, Université libre de Bruxelles, Brussels, Belgium
3Service d’ORL et de chirurgie cervico-faciale, CUB Hôpital Erasme, Université libre de Bruxelles, Brussels, Belgium
Purpose: Altered neuromuscular strategies are suggested to contribute to the elderly’s poor postural control, but previous work tends to assess the involvement of lower leg muscles only, despite the fact that stability depends on multi-joint coordination. This study aims to shed novel insight on postural strategies in the elderly by assessing global (whole-body) neuromuscular control using the co-contraction index (CCI) and muscle synergy analysis (MSA).
Methods: Young (18-35 years, n = 32) and older (65-85 years, n = 33) participants stood upright for 10 minutes on a hard surface or foam pads with eyes closed or open. Center of pressure (COP) was assessed by force plate and the activity of 15 bilateral muscles, by electromyography. Muscle co-contraction magnitude was measured with Falconer’s CCI, while MSA by non-negative matrix factorization, followed by k-means clustering. Postural instability was assessed by excursion and velocity of COP.
Results: A two-way ANOVA revealed that age (p < 0.0001) and condition (p < 0.0001), but not their interaction affected global CCI values, where the elderly possessed increased CCI values across conditions. The MSA revealed more frequent use of a knee-extensor synergy in the elderly (p < 0.0001; permutation-based statistics). Instability parameters were pooled due to high correlation (r > 0.83, p < 0.0001). Spearman correlations revealed significant relationships within all conditions between pooled instability and the elderly’s global and knee-extensor CCIs (r = 0.381-0.522, p < 0.002; r = 0.392-0.435, p < 0.002), but not lower leg-based CCIs (p > 0.05).
Conclusions: Global co-contraction appears to be a signature of elderly postural strategy and a substantial contributor to postural instability. Future work will be necessary to determine whether such co-contractions are the result of altered cortical and spinal reciprocal inhibition to antagonist muscles, compensation for loss of sensory input, or a fear-driven stability-limit response.
Bed rest impairs the vestibular control of balance
Stuart Mackenzie1, Craig Smith1, Malcom Tremblay2, Brian Day3, Raymond Reynolds1
1School of Sport, Exercise & Rehabilitation Sciences, University of Birmingham, UK
2Department of Biomedical Physiology and Kinesiology, Simon Fraser University, Canada
3Department of Clinical and Movement Neurosciences, University College London, UK
Purpose: Prolonged bed rest impairs standing balance but the underlying mechanisms are uncertain. Previous research suggests strength loss is not the cause, leaving impaired sensorimotor control as an alternative. Here we examine vestibular control of posture in 18 male volunteers before and after 60 days of bed rest.
Methods: Stochastic vestibular stimulation (SVS) was used to evoke sway responses before, 1 & 6 days after bed rest under different head yaw orientations. The directional accuracy and precision of these responses were calculated from ground reaction force vectors.
Results: Bed rest caused up to 63% increases in spontaneous standing sway and 31% reductions in leg strength, changes which were uncorrelated. The increase in sway was exacerbated when the eyes were closed. Mean directions of SVS-evoked sway responses were unaffected, being directed towards the anodal ear and rotating in line with head orientation in the same way before and after bed rest. However, individual trial analysis revealed 25-30% increases in directional variability which were significantly correlated with the increase in spontaneous sway (r=0.48-0.71; p ≤ 0.044) and were still elevated on day 6 post-bed rest.
Conclusions: We have shown that vestibular-evoked sway responses may be inappropriately oriented after a prolonged period of inactivity, a finding masked by the averaging process. Our results confirm that impaired balance following prolonged bedrest is not related to loss of strength. Rather, they demonstrate that the sensorimotor transformation process which converts vestibular feedback into appropriately directed balance responses is impaired.
Enhancing virtual reality with artificial vestibular stimulation
Juno Kim1, Peter Wagner1, Shinichi Iwasaki2, Stephen Palmisano3
1University of New South Wales
2Nagoya City University
3University of Wollongong
Purpose: To assess the effectiveness of artificial vestibular stimulation (e.g., galvanic vestibular stimulation – or GVS) in enhancing positive experiences (and mitigating negative experiences) in head-mounted display (HMD) based virtual reality (VR).
Methods: We recruited 20 healthy participants at UNSW Sydney. Surface gel electrodes were positioned over each mastoid bilaterally to deliver GVS at intensities controlled to ±1.0 mA. Standing participants viewed simulations of self-motion over a simulated 3D terrain using the Oculus Rift S HMD. Four viewing conditions were imposed: (i) pure radial flow simulating constant-velocity self-motion in depth; (ii) viewpoint perspective oscillation simulating self-motion along a curvilinear pathway; and simulated viewpoint perspective oscillation with GVS either (iii) synchronized or (iv) inversely synchronized to expected interaural inertial forces. Postural sway was recorded using a Bertec force plate in addition to subjective experiences of vection, presence and cybersickness.
Results: Visually simulated viewpoint oscillation alone increased vection compared to pure radial flow. However, adding synchronized GVS further increased vection and also increased presence compared to viewpoint oscillations alone. Surprisingly, inverse GVS also increased vection (but to a lesser extent). Reported cybersickness was quite weak during GVS – as measured by the fast-motion sickness (FMS) scale. Subjective experiences were able to be explained by coupling of the postural-sway responses to the simulated viewpoint oscillations with or without GVS.
Conclusions: Our findings suggest that artificial vestibular stimulation (e.g., GVS) increases immersive experiences during HMD VR, without significantly increasing cybersickness. These enhancements in the user experience appear to be attributable to complex multisensory processes that mediate postural stability.
Frequency analyses of postural sway demonstrate the use of sounds for balance given vestibular loss
Anat Lubetzky1, Maura Cosetti2, Daphna Harel1, Katherine Scigliano2, Marlee Sherrod1, Agnieszka Roginska1, Jennifer Kelly2
1New York University, NY, USA
2New York Eye and Ear Infirmary of Mount Sinai, NY, USA
Purpose: To investigate how adults with vestibular loss and healthy controls incorporate visual and auditory cues for postural control.
Methods: Participants stood on foam wearing the HTC Vive, observing an immersive 3-wall display of ‘stars’ that were either static or dynamic (moving front to back at 32mm, 0.2Hz) with no sound, static white noise or moving white noise projected from headphones. Each 60-second condition repeated twice. We recorded the center-of-pressure variance, and its power spectral density [PSD, cm2] components in low [0, 0.25Hz], mid [0.25, 0.5Hz] and high [0.5, 1Hz] frequencies in the anterior-posterior direction. We compared healthy controls (n=41, mean age 52 years, range 22-78) to participants with unilateral peripheral vestibular hypofunction (n=28, 61.5, 27-82, adjusting for age differences through linear mixed-effects models.
Results: Variance and low PSD: we observed a significant vestibular by visual load interaction in the presence of sounds, such that the vestibular group had significantly higher sway than controls only on dynamic visuals in the presence of sounds. Mid PSD: the vestibular group had significantly higher sway than controls regardless of condition. High PSD: the vestibular group had significantly higher sway than controls, except for the presence of sounds on static visuals.
Conclusions: Patients with vestibular hypofunction used sounds to reduce sway in a static abstract environment and were somewhat destabilized by it in a dynamic environment. This suggests that sounds can function as an auditory anchor under certain level of challenge and specific tasks. Our results support that increased sway in middle frequencies reflects vestibulardysfunction.
Gait impairments in patients with bilateral and chronic unilateral vestibulopathy
Anissa Boutabla1, Rebecca Revol1, Marys Franco Carvalho2, Gautier Grouvel1, Julie Corre1, Jean-François Cugnot1, Samuel Cavuscens1, Maurizio Ranieri1, Raymond Van de Berg3, Stéphane Armand2, Angélica Pérez Fornos1, Nils Guinand1
1Division of Otorhinolaryngology Head and Neck Surgery, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
2Kinesiology Laboratory, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
3Division of Balance Disorders, Department of Otorhinolaryngology and Head and Neck Surgery, Maastricht University Medical Center, Maastricht, the Netherlands.
Purpose: Vestibular deficits often lead to unsteady gait, affecting quality of life and increasing fall risk. This study aimed to identify objective gait metrics and their correlation with validated clinical gait tests and patient symptoms (i.e., unsteadiness when walking).
Methods: Ten bilateral vestibulopathy (BV) patients, 10 unilateral vestibulopathy (UV) patients, and 10 healthy subjects, age- and sex-matched, participated in this study. Spatio-temporal parameters were recorded using an optoelectronic system at various self-selected walking speeds (comfortable, slow, fast), along with clinical tests (functional gait assessment (FGA), tandem walk (TW), timed “up and go” (TUG)), and symptom severity assessments using the Dizziness Handicap Inventory (DHI).
Results: BV and UV patients showed significant slower walking speeds, shorter step lengths, and broader step widths than HS, but similar cadence (p<0.001). Differences were also seen in stance phase, double and single support phases at comfortable and slow speeds (p<0.001), but not at fast speeds (p =0.193). BV patients had worse FGA scores than HS (p<0.001), with no differences for UV patients. Tandem walk performance was lower in BV BV than other groups (p<0.001), with no differences in TUG scores. Cluster analysis revealed two distinct clusters: one with all HS and most UV patients (70%), and another with most BV patients and 30% of UVs with no significant correlations to DHI scores.
Conclusions: Overall, this study highlights how altered vestibular function impacts gait patterns and clinical gait assessment outcomes. These findings can aid clinicians in evaluating gait in patients with vestibular deficits and monitoring rehabilitation interventions.
Motor Competence in School-Aged Children at risk of Hearing and/or Vestibular Loss: an overview
Ruth Van Hecke1, Ingeborg Dhooge2, Cleo Dhondt3, Sarie Martens1, Marieke Sucaet4, Saartje Vanaudenaerde4, Lotte Rombaut4, Els De Leenheer4, Helen Van Hoecke4, Frederik J.A. Deconinck5, Leen Maes6
1Ghent University, Department of Rehabilitation Sciences, Belgium
2Ghent University (Hospital), Department of Otorhinolaryngology/Head and skin, Belgium
3Ghent University, Department of Head and skin, Belgium
4Ghent University Hospital, Department of Otorhinolaryngology, Belgium
5Ghent University, Department of Movement and Sports Sciences, Belgium
6Ghent University (Hospital), Department of Otorhinolaryngology/Rehabilitation Sciences, Belgium
Purpose: Based on research and clinical experience, our ENT department developed an extensive protocol including auditory, vestibular and motor assessments for all children at risk of audiovestibular disorders, offering a holistic perspective on the motor competence of the pediatric population consulting the otologic department.
Methods: Between October 2017 and October 2021, we enrolled all school-aged children (4.0 – 16.9 years old) who were either in follow-up or referred to the department due to a risk of hearing and/or vestibular problems; i.e. having auditory and/or vestibular complaints, a medical history with ototoxic drugs, inner ear malformations, a head trauma, genetic mutations linked to audiovestibular loss, or evidence of prior infections that have been related to auditory/vestibular problems in literature. Preceded by an extensive history-taking session and ENT appointment, the protocol included tympanometry, otoacoustic emissions, audiometry, a horizontal and vertical video Head Impulse test, cervical and ocular Vestibular Evoked Myogenic Potentials, rotatory chair and caloric irrigation testing, and the Movement Assessment Battery for Children, 2nd edition (MABC-2).
Results: Among the 117 participants (59 boys; 7.3 ± 3.1 years), four groups could be identified: those with hearing loss (n=33), combined hearing and vestibular loss (n=47), isolated vestibular loss (n=5), and those without audiovestibular deficits (n=32). Group differences revealed diminished fine motor skills, as well as lower balance and total MABC-2 scores in the group with combined hearing and vestibular dysfunctions (p< 0.001), particularly in children with severe bilateral deficits. Of this subgroup, the majority (38/47; 80.9%) were referred for additional monitoring of their motor functioning and/or physical therapy.
Conclusions: This first large-scale study encompassing school-aged children at risk of audiovestibular disorders revealed a diverse clinical presentation among them. Nonetheless, crucial trends and influential factors emerged, underscoring the importance of adopting a holistic approach to the assessment and management of pediatric auditory and vestibular concerns.
Postural recovery following spaceflight
Scott Wood
1
1NASA Johnson Space Center, Houston TX USA
Purpose: The need to move and maintain awareness of spatial orientation in altered gravity environment drives sensorimotor adaptation and learning to acquire a new set of synergies optimized for the novel environment. The perceptual and motor coordination problems experienced postflight reflect the recalibration of predicted versus actual movement feedback that is required for readaptation back to the natural gravitational state.
Methods: The duration of microgravity exposure has a significant effect on both the magnitude of the sensorimotor decrements and the time course of recovery to preflight performance levels. This effect of spaceflight duration is illustrated by comparing results from Shuttle and the International Space Station (ISS) astronauts on computerized dynamic posturography that have been routinely conducted as part of medical operations and research studies.
Results: While there have been reports of otolith-mediated reflexes being modified by prior flight experience, the postflight functional performance as assessed by computerized dynamic posturography does not appear altered with prior flight experience. Although anecdotal reports suggest prior flight experience may result in some carry over of fine motor strategies needed to control motion in the novel “microgravity” state, this postflight recalibration to “normal gravity” appears necessary with each subsequent mission.
Conclusions: The early sensorimotor decrements have implications for the completion of critical mission tasks during and following g-transitions. Interventions are necessary to optimize crew performance for success on upcoming exploration missions.
Quantitative evaluation of gait and stance in patients with acute vertigo and dizziness
Ken Möhwald1, Hristo Hadhizolev1, Patricia Jaufenthaler2, Max Wuehr2, Klaus Jahn2, Andreas Zwergal1
1LMU University Hospital, German Center for Vertigo and Balance Disorders (DSGZ) & Department of Neurology, Munich, Germany
2LMU University Hospital, German Center for Vertigo and Balance Disorders (DSGZ), Munich, Germany
Purpose: Systematic and quantitative investigations of gait and stance parameters in patients with acute vertigo and dizziness are largely missing. The aim of this study was to collect objective markers of gait and stance in a patient cohort with these chief complaints and compare the degree of impairment between peripheral and central etiologies.
Methods: We prospectively included 407 patients (60.9±16.9y, 46% female) and conducted a standardized gait and stance assessment during the acute symptomatic stage using Functional Gait Assessment (FGA), Timed-Up-and-Go Test (TUG), mobile posturography (Wii Balance Board) with four conditions – normal stance/tandem stance with eyes open/closed. Final diagnoses were made upon further diagnostic assessment (e.g., by MRT/vHIT/VOG). We compared FGA, TUG, and sway path in xy-direction for all posturographic test conditions in patients with acute central lesions (stroke, n=64), patients with acute unilateral vestibulopathy (AUVP, n=47) and patients with definite episodic vestibular disorders (Menière’s disease, vestibular migraine, n=88) using logistic regression models and ROC curve analyses adjusted for age and sex.
Results: Patients with AUVP had significantly lower FGA scores and higher TUG scores than patients with central lesions and episodic vestibular disorders (FGA: 15.1/19.9/24.1 points; TUG: 12.1/10.2/8.6s). The ROC-AUC values were 0.79 for FGA and 0.78 for TUG comparing AUVP vs. stroke. In the normal stance/eyes open condition, 10% of stroke patients and 13% of AUVP patients were not able to stand unassisted, while all patients with episodic vestibular disorders could master this task. Sway path was significantly higher in AUVP during tandem stance compared to central and episodic disorders only, but not for normal stance (eyes open or closed).
Conclusions: Gait performance is more severely affected in patients with AUVP compared to vestibular stroke. Differences in postural control between various etiologies are more visible in advanced stance and gait conditions such as tandem stance, FGA or TUG.
Real sounds influence postural stability in people with vestibular loss but not in healthy controls
Anat Lubetzky1, Maura Cosetti2, Daphna Harel1, Katherine Scigliano2, Zhu Wang1, Agnieszka Roginska1, Jennifer Kelly2
1New York University, NY, USA
2New York Eye and Ear Infirmary of Mount Sinai, NY, USA
Purpose: What we hear may influence postural stability similar to what we see, particularly among those with vestibular hypofunction. We investigated how individuals with vestibular hypofunction and healthy controls incorporate broadband and contextual sounds with visual load for balance.
Methods: We measured standing balance of 41 healthy controls (mean age 52, range 22-78) and 28 participants with peripheral vestibular hypofunction (61.5, 27-82) when participants were wearing the HTC Vive headset, observing an immersive subway environment. There were 6, 60-second conditions, each repeated twice: static or dynamic visual with no sound or static white noise [noise] or real recorded subway station sounds [real] projected from headphones. Participants were standing on foam placed on a force-platform. We quantified center-of-pressure (COP), root mean square velocity (cm/s) from the force-platform (anterior-posterior, medio-lateral) and head (anterior-posterior, medio-lateral, pitch, yaw, roll) from the headset.
Results: Adjusting for age, the vestibular group was significantly higher than controls on COP medio-lateral (no sound or real on either static or dynamic visual); COP anterior-posterior (only on dynamic visuals in the presence of either sound); head medio-lateral and anterior-posterior (all conditions), head pitch and yaw (only on dynamic visuals in the presence of either sound). A significant increase in sway with sounds was observed for the vestibular group only on dynamic visuals COP anterior-posterior (real) and head anterior-posterior (either sound).
Conclusions: The addition of auditory stimuli, particularly contextually-accurate sounds, to a challenging, standing balance task in real-life simulation influenced postural control in people with vestibular hypofunction but not healthy controls.
Restoration of population dynamics in vestibular pathways during locomotion via biomimetic prosthetic stimulation
Ruihan Wei1, Oliver Stanley1, Kathleen Cullen1
1Johns Hopkins University, School of Medicine, Department of Biomedical Engeering, U.S.A
Purpose: Patients with vestibular sensory loss experience debilitating gaze instability and postural imbalance. By establishing how the brain selectively modulates vestibulospinal pathways to ensure locomotor stability, our study provides a foundation to facilitate the diagnosis and treatment of vestibular dysfunction and to facilitate improvements in locomotion rehabilitation following such dysfunction.
Methods: Using high-density (128 channels) electrodes, we recorded neural activity from the vestibular nuclei (VN) of normal and bilateral vestibular loss macaques. Head and trunk positions were tracked using a 6D motion sensor and marker-based systems, while limb motion was captured with high-speed cameras via markerless motion capture. We assessed single-unit activity and head stabilization during overground and treadmill walking at different speeds.
Results: Our results demonstrate that: 1) VN neurons in normal animals show phase-dependent responses during locomotion. 2) When analyzed in a low-dimensional subspace, VN population responses occupy a specific shared pattern across conditions which is dynamically modulated. 3) In the absence of vestibular input, VN neurons exhibit a lack of phasic modulation during locomotion. In the presence of head-coupled vestibular prosthetic stimulation, this modulation is restored.
Conclusions: Given their close simmilarity in neural and physiological structures to humans, rhesus macaques serve as a key model for exploring the mechanisms behind vestibular dysfunction. Our study highlights the vestibular system’s essential role in the sensorimotor integration required to maintain balance during locomotion.
Specificities of postural control in top-level skiers in different events
Philippe Perrin1, Nicolas Coulmy2, Art Mallinson3, Eric Blin4, Flavio Perottino5, Georges Dumas6
1University of Lorraine, University Hospital of Nancy, Vandoeuvre-lès-Nancy, France
2French Ski Federation, Sports and Scientific Department, Annecy, France
3Division of Otolaryngology, Faculty of Medicine, University of British Columbia, Vancouver, Canada
4Vestibular physiotherapy, Enghien-lès-Bains, France
5Otolaryngology, Briançon, France
6University Hospital, Grenoble, University of Lorraine, France
Purpose: The specific aspects of postural control in elite skiers, according to the discipline practiced, were evaluated in alpine skiing (slalom, downhill, super-G) and in freestyle skiing (aerials, moguls, cross, half-pipe, slopestyle and big air).
Methods: Twenty-one elite skiers (4 of them medallists at the Olympic Games and/or World Championships) completed a questionnaire regarding their specific event, level of training, and history of sport related injury.
This was followed by an interview and clinical examination. Balance control was evaluated using computerized dynamic posturography (CDP, EquiTest) Sensory Organization Test and Head Shaking Test (head tilts of 30° in the pitch plane).
Results: Four skiers (all freestyle skiers) had a history of head injury, including one with five head injuries, with loss of consciousness in three. Eleven skiers (mostly aerial skiers) suffered knee injuries. Four skiers described a sensation of motion sickness when skiing.
The weight of sensory afferences measured by CDP (i.e. postural control strategies) was correlated with the discipline practiced, with the type of trauma (brain/vestibular injury, knee, e.g. cruciate ligament rupture), and the type of trauma was correlated with the discipline practiced.
Conclusions: By highlighting specific aspects of postural control, weaknesses can be managed during the off-season (summer for skiers) and strengths can be reinforced/exploited during the ski season.
This may be help to modify training regimens. Ski equipment could also be modified. Hopefully this will result in prevention and management of injury, including head injury/concussion. Return to competition following injury should include specifically directed rehabilitation programmes with strict timetables.
Sway patterns in chronic unilateral vestibulopathy due to schwannoma compared to healthy controls
Torbjørn Egeland Torp1, Hai Quan Dinh Nguyen1, Geir Egil Eide2, Frederik Kragerud Goplen3
1Faculty of Medicine, University of Bergen, Bergen, Norway
2Centre for Clinical Research, Haukeland University Hospital, Bergen, Norway
3Department of Otorhinolaryngology & Head and Neck Surgery, Haukeland University Hospital, Bergen, Norway
Purpose: To examine the difference in posturographic sway patterns between patients with untreated vestibular schwannoma and healthy controls of different age using different methods of posturography.
Methods: Study Design: Prospective, observational study. Setting: Outpatient clinic and hospital. Patients: Newly diagnosed, untreated vestibular schwannoma patients, healthy medical students and outpatients matched to the schwannoma patients for age and sex. Interventions: Static posturography during quiet stance for 60 s with eyes open (EO) and closed (EC). Dynamic posturography (EquiTest™) using the Sensory Organization Test protocol (SOT). Main Outcome Measures: For static posturography path length of center of pressure. For dynamic posturography SOT1 – SOT 6. Statistics: Factor analysis and logistic regression.
Results: Factor analysis identified three main factors responsible for variation in postural sway. Factor 1, responsible for the largest variation, had highest loading on SOT1-4. Factor 2 had highest loading on SOT5-6 and distinguished best between patients and age-matched controls. Factor 3 had highest loading on EO and EC and distinguished best between healthy subjects of different age
Conclusions: This study demonstrated three patterns of postural sway in patients with vestibular schwannoma and healthy controls of different age. These patterns should not be taken as pathognomonic or diagnostic but are to a varying degree associated with peripheral vestibular disease (factor 2), age (factor 3) and possibly also with anxiety or unfamiliarity with the test setting (factor 1), a pattern formerly described as “aphysiologic”, a designation that is probably misleading since the pattern was the most common in patients as well as in healthy controls.
The effect of active head movements on walking, mapped by spatiotemporal gait parameters in healthy adults
Eugénie Lambrecht1, Luc Vereeck1, Willem De Hertogh1, David Beckwée2, Ann Hallemans1
1Research Group MOVANT, Department of Rehabilitation Sciences and Physiotherapy (REVAKI), Antwerp University, Wilrijk, Belgium
2Rehabilitation Research Group (RERE), Vrije Universiteit Brussel, Brussels, Belgium
Purpose: This study investigates the impact of active, augmented reality (AR) induced head movements during normal walking on spatiotemporal gait parameters in healthy adults.
Methods: A cross-sectional study was carried out including 34 healthy adults (12 male/22 female; age of 24.09±2.54). Participants were instructed to walk an overground 7-meter walkway wearing an AR head-mounted display (HMD) (Hololens2®Microsoft LLC). The AR-HMD projected a hologram moving vertically (up,down) or horizontally (left,right) tracked with head and eyes by the participants, this way inducing a head and eye movement while walking. A 3D-motion capture system recorded at least 30 walking trials for each participant. Spatiotemporal parameters (steplength, -width and -time) were analysed before (baseline), during (perturbed) and after (recovery) the head movement. Data processing was performed in Nexus software and MATLAB. SPSS was used for statistical analysis using paired t-tests with Bonferonni correction (p<0.017).
Results: Comparing baseline and perturbed spatiotemporal parameters revealed significant differences in steplength for all four head movement directions (p<0.001), as well as in steptime during flexion (p=0.008) and stepwidth during left horizontal rotation (p=0.005). Comparing perturbed steps with recovery steps showed significant differences in steplength during flexion (p=0.011) and left horizontal rotation (p<0.001), along with steptime during flexion (p=0.004) and right horizontal rotation (p=0.009). No significant differences were found when comparing recovery with baseline, except in steplength during right horizontal rotation (p=0.010).
Conclusions: Performing head movements while walking shows significant differences in walking patterns as indicated by spatiotemporal parameters. The most pronounced changes were found in steplength when comparing perturbed steps with baseline, with differences in steptime and -width less frequently observed. Notably, differences appear to be dependent on the direction of the head movement. Recovery was not remarkably different than baseline, suggesting that the perturbing effect of the head movement might not persists when the head is rotated back to neutral position.
The Effects of Noisy Galvanic Vestibular Stimulation to Perturbations of Balance and Muscle Activity
Mohammad Mahmud1, Isha Sohail1, Zaeem Hadi1, Barry M Seemungal1, Toby J Ellmers1
1Centre for Vestibular Neurology, Department of Brain Sciences, Imperial College London, UK
Purpose: The vestibular system is crucial for balance control and is affected by age-related deterioration. These deficits can cause an increased risk of falling, and require novel therapies in frail persons with multiple morbidities. Noisy galvanic vestibular stimulation (nGVS), a non-invasive technique, offers such a potential avenue. This involves a weak, subthreshold stimulation to the vestibular system that theoretically enhances balance. Based on multiple positive randomised double blinded trials on static balance we now aimed to explore the effects of nGVS on reactive balance.
Methods: A randomised double-blinded, sham-controlled trial of 30 healthy young adults was conducted. A stimulation intensity of +/-350 µA (1-250Hz) or sham was given during each perturbation. Perturbations consisted of discrete forwards platform movement (peak velocity = 32 cm/s, maximum forward displacement = 14cm), akin to a train suddenly moving. Peak-to-peak velocity (deg/s) of trunk sway was calculated as a measure of postural instability. Muscular activity (EMG) of the tibialis anterior leg muscle (responsible for stabilising posture following forward movement of a platform) was assessed.
Results: nGVS led to small but significant reductions in peak trunk velocity, compared to sham GVS. There were no significant differences between nGVS vs. sham GVS for any of the EMG outcomes assessed.
Conclusions: This study extends the research that has explored the effects of nGVS on static balance, and provides initial evidence that nGVS can also enhance balance responses to external perturbations.
Therapeutic potential of low-intensity vestibular noise stimulation in Parkinson’s disease and atypical parkinsonism
Andreas Zwergal1, Klaus Jahn2, Max Wuehr2
1LMU University Hospital, German Center for Vertigo and Balance Disorders (DSGZ) & Department of Neurology, Munich, Germany
2LMU University Hospital, German Center for Vertigo and Balance Disorders (DSGZ)
Purpose: Postural imbalance, gait dysfunction, and falls are significant complications in Parkinson’s disease (PD) and related movement disorders, possibly related to impaired vestibular, particularly vestibulo-spinal function. Low-intensity vestibular noise stimulation (noisy galvanic vestibular stimulation; nGVS), proven effective in treating postural impairment in chronic peripheral vestibular hypofunction, is now being increasingly explored for its therapeutic potential in PD and atypical parkinsonian syndromes like progressive supranuclear palsy (PSP). Here we will summarize the available clinical evidence regarding the therapeutic effects of nGVS in PD and atypical parkinsonian syndromes.
Methods: We performed several experimental studies comparing the therapeutic effects of nGVS versus sham stimulation on motor symptoms, static and dynamic postural function, and gait performance in patients with PD and atypical parkinsonian syndromes.
Results: nGVS demonstrated clinically relevant postural stabilization in approximately half of the treated patients with PD and PSP, particularly benefiting those with advanced instability. However, while treatment effects improved static and dynamic balance control, no observable enhancement was noted in impaired gait dysfunction during treatment.
Conclusions: nGVS presents a promising non-invasive and well-tolerated treatment approach to mitigate postural instability in patients with PD and atypical parkinsonian syndromes. A selective modulation of midbrain-thalamic circuits of balance control by nGVS may explain its differential effects on static postural function versus gait.
TMS of the left primary motor cortex improves tremor intensity and postural control in primary orthostatic tremor
Florian Schöberl1, James Dowsett2, Cauchy Pradhan3, Denis Grabova3, Angelina Köhler3, Paul Taylor4, Andreas Zwergal5
1LMU University Hospital, Department of Neurology, Munich, Germany
2University of Stirling, Division of Psychology, Stirling, UK
3LMU University Hospital, German Center for Vertigo and Balance Disorders (DSGZ), Munich, Germany
4LMU Munich, Faculty of Philosophy, Philosophy of Science and the Study of Religion, Munich, Germany
5LMU University Hospital, German Center for Vertigo and Balance Disorders (DSGZ) & Department of Neurology, Munich, Germany
Purpose: A ponto-cerebello-thalamo-cortical network is the pathophysiological correlate of primary orthostatic tremor. Affected patients often do not respond satisfactorily to pharmacological treatment. Consequently, the objective of the current study was to examine the effects of a non-invasive neuromodulation by theta burst repetitive transcranial magnetic stimulation (rTMS) of the left primary motor cortex (M1) and dorsal medial frontal cortex (dMFC) on tremor frequency, intensity, sway path and subjective postural stability in primary orthostatic tremor.
Methods: In a cross-over design, eight patients (mean age 70.2 ± 5.4 years, 4 female) with a primary orthostatic tremor received either rTMS of the left M1 leg area or the dMFC at the first study session, followed by the other condition (dMFC or M1 respectively) at the second study session 30 days later. Tremor frequency and intensity were quantified by surface electromyography of lower leg muscles and total sway path by posturography (foam rubber with eyes open) before and after each rTMS session. Patients subjectively rated postural stability on the posturography platform following each rTMS treatment.
Results: We found that tremor frequency did not change significantly with M1- or dMFC-stimulation. However, tremor intensity was lower after M1- but not dMFC-stimulation (p=0.033/p=0.339). The sway path decreased markedly after M1-stimulation (p=0.0005) and dMFC-stimulation (p=0.023) compared to baseline. Accordingly, patients indicated a better subjective feeling of postural stability both with M1-rTMS (p=0.007) and dMFC-rTMS (p=0.01).
Conclusions: Non-invasive neuromodulation particularly of the M1 area can improve postural control and tremor intensity in primary orthostatic tremor by interference with the tremor network and could be a promising add-on therapy for affected patients.
Towards an explanation for ‘unexplained’ dizziness in older people
Patricia Castro1, Richard Ibitoye2, Toby Ellmers2, Diego Kaski3, Qadeer Arshad4, Adolfo Bronstein2
1Imperial College London, Universidad del Desarrollo
2Imperial College London
3University College London
4University of Leicester
Purpose: Subjective unsteadiness or dizziness is common in older people usually without increase in body sway. The absence of mechanistic understanding of such symptom renders clinical management difficult for clinicians. Here, we explore the mechanisms behind such idiopathic dizziness, focusing on postural control abnormalities.
Methods: Thirty patients with idiopathic dizziness and 30 age-matched controls stood on a moving platform. Platform oscillations were randomly delivered at different velocities (from 0 to 0.2m/s). Markers of postural control including objective sway (trunk sway path, recorded via a sensor attached to vertebrae C7), stepping responses and subjective instability and anxiety ratings, were obtained. MRI scans were available for correlations with levels of cerebral small vessel disease in 28 patients and 24 age-matched controls.
Results: We observed a significant relationship between objective and subjective instability in all groups. The slope of this fit was significantly steeper for patients than controls, indicating greater perceived instability for the same body sway. Stepwise linear regression showed the slopes of this objective-subjective instability relationship were best explained by self-reported concerns about falling (Falls Efficacy Scale-International), clinical physical functioning (Short Physical Performance Battery) and, to some degree, by neuroimaging markers of cerebral small vessel disease. In addition, patients had a reduced stepping threshold, suggesting an overly-cautious postural response.
Conclusions: The distorted perception of instability and subtle impairments in balance control, including abnormal and overly-cautious stepping responses, underlies the emergence of idiopathic dizziness. It appears to relate to changes in postural performance, psychological functioning, and disruption of postural brain networks associated with cerebral small vessel disease.
Unperturbed and perturbed gait variability in bilateral vestibulopathy vs. age-matched controls
Meichan Zhu1, Lisa van Stiphout1, Rik Marcellis2, Rachel Senden2, Mustafa Karabulut1, Paul Willems3, Angélica Pérez Fornos4, Nils Guinand4, Kenneth Meijer3, Raymond van de Berg1, Christopher McCrum3
1Department of Otorhinolaryngology and Head and Neck Surgery, Division of Balance Disorders, Maastricht University Medical Center, School for Mental Health and Neuroscience, Maastricht, The Netherlands
2Department of Physical Therapy, Maastricht University Medical Center, Maastricht, Limburg, The Netherlands
3Department of Nutrition and Movement Sciences, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands
4Service of Otorhinolaryngology and Head and Neck Surgery, Department of Clinical Neurosciences, Geneva University Hospitals, Geneva, Switzerland
Purpose: Balance and gait deficits, including increased gait variability, are common in bilateral vestibulopathy (BVP). Since previous studies have rarely matched participants on age and sex and have typically assessed gait variability only during unperturbed walking, we aimed to compare gait variability in people with BVP to an age- and sex-matched healthy control group during both unperturbed and perturbed walking tasks.
Methods: Forty-five people with BVP and 45 healthy age- and sex-matched healthy adults walked at 0.6m/s, 0.8m/s, and 1.0m/s on an instrumented treadmill embedded in a 6-degrees-of-freedom motion platform (Computer Assisted Rehabilitation Environment; Motek). Three conditions were used: unperturbed walking and walking with two different intensities of pseudorandom mediolateral platform sway creating unpredictable motions of the walking surface. Using 3D motion capture data, the coefficients of variation for step time, step length, double support time and step width were calculated.
Results: Two-way ANOVAs with factors walking speed and group found significantly more variability (P<0.05) in BVP for step time, step length and double support time during all three conditions. Two-way ANOVAs with walking speed and task condition as factors did not reveal significant task differences between these parameters in either group. Only step width variability significantly increased during the perturbations but this did not differ between groups.
Conclusions: People with BVP have more gait variability compared to healthy controls, independent of sex and age. Small mediolateral walking surface sway perturbations do not appear to increase this difference. A study of additional gait stability parameters and additional task conditions is needed.
Validating the usage of head movements induced by augmented reality in gait stability assessment
Eugénie Lambrecht1, Jakob Struye2, David Beckwée3, Willem De Hertogh1, Luc Vereeck1, Ann Hallemans1
1Research Group MOVANT, Department of Rehabilitation Sciences and Physiotherapy (REVAKI), Antwerp University, Wilrijk, Belgium
2IDLab, Department of Computer Science, Antwerp University, Antwerp, Belgium
3Rehabilitation Research Group (RERE), Vrije Universiteit Brussel, Brussels, Belgium
Purpose: The main aim of this study is to evaluate if head movements induced by augmented-reality (AR) is a valid method in gait stability assessment in healthy individuals. This study investigates the influence of the hardware of an AR head-mounted display (HMD) on head kinematics. Secondly it seeks to determine if an AR-HMD setup can elicit equally reproducible head movements compared to traditional, broadly used auditory cue methods such as in the Dynamic Gait Index, Functional Gait Assessment etc.
Methods: In a cross-sectional study involving 25 healthy adults (9 male/15 female; age 24.14; body mass index 23.20±2.64), participants were assessed on gait stability. They walked a 7-meter overground walkway under three different conditions: 1) head turn with auditory cue only, 2) head turn with auditory cue while wearing the AR-HMD (AR cue not activated), 3) head turn with AR cue by the AR-HMD. Head kinematics (range of motion, peak velocity) during horizontal and vertical head movements were measured using a Vicon 3D-motion capture system. Statistical analyses were conducted using linear mixed models and ANOVA in RStudio.
Results: All participants performed at least 42 walking trials. A significant difference was found in peak head velocity (p<0.001), but not in range of motion (p=0.3044) of the evoked head turn between condition 1 and 2, suggesting an effect of hardware solely on peak head velocity. Similarly, a significant difference in variance was found in peak head velocity (p<0.05), but not in range of motion (p=0.667) between condition 2 and 3. There was an indication that the condition's effect varied based on movement direction, although not significant.
Conclusions: In conclusion, an AR-HMD setup significantly influences peak head velocity but not range of motion when inducing a head movement during gait stability analysis compared to the traditional auditory cue setup.
Validation of a smartphone-based system for analysis of balance
Erik Faergemann1, Helena Grip2, Solmaz Surano1, Jonatan Salzer1, Fredrik Öhberg2
1Department of Clinical Sciences, Neurosciences, Umeå University, Umeå, Sweden
2Department of Diagnostics and Intervention, Biomedical Engineering and Radiation Physics, Umeå University, Umeå, Sweden
Purpose: There is a need for user-friendly and dependable approaches to quantify and follow vertigo symptoms over time. The inclusion of smartphone motion-tracking capabilities offers the potential for creating a widely accessible platform for evaluating balance function.
Methods: A smartphone-based system for evaluating balance function was compared to a wearable motion capture system. Participants performed four distinct balance tasks while standing to assess the smartphone-based system’s ability to differentiate between various conditions.
Intraclass correlations were utilised for reliability analysis and systemic differences were analysed with Bland-Altman plots. By using Friedmans test with post hoc Dunn’s Pairwise comparison, the degrees of Sway Magnitude, Sway-Path Acceleration and Sway-Path Angular Velocity were compared between different balance tasks with varying difficulty levels (open/closed eyes, head still/head rotations).
Results: A total of 54 participants (28 female, age 18–94) were included. The smartphone-based system showed excellent to good agreement (interclass correlation ≥0.75) with the wearable multisensory system for Sway Magnitude, Sway-Path Acceleration and Sway-Path Angular Velocity. Both systems showed good differentiation between the tasks for the parameters Sway Magnitude and Sway-path (p<0.001 for most comparisons). Some systematic differences were found which could relate to varying sensitivity of the sensors and slightly different positions of the sensors on the pelvic segment.
Conclusions: In conclusion we have shown that the smartphone application ErgoExposure reliably measures Sway Magnitude, Sway-Path Acceleration and Sway-Path Angular Velocity and distinguishes between different balance task difficulties. This offers a promising outlook for use of such smartphone applications in a clinical setting for vertigo assessment and pave the way for further studies to investigate if ErgoExposure may differentiate between healthy individuals and those who have balance difficulties and detect successive balance recovery after a vestibular insult.
Walking and Standing Characteristics in Stroke Patients with and without Vestibular Symptoms
Yue Zhang1, Miaomiao Yin1, Yaqing Li1, Liling Cui1, Liqun Wang1, Jialing Wu1
1Huanhu hospital, Tianjin, China
Purpose: To explore the differences in walking and standing characteristics between stroke patients with and without vestibular symptoms.
Methods: 82 stroke patients and 49 control subjects matched for gender, age, and education level were included in this study. Stroke patients were divided into vestibular symptom group (51 cases) and non-vestibular symptom group (31 cases) according to the presence or absence of vestibular symptoms. The 7-meter gait test was used to evaluate walking stability, and the sensory organization test (CTSIB) was used to evaluate standing balance stability.
Results: The results of the 7-meter gait test showed that the differences in spatial and temporal parameters of gait, trunk coronal swing angle, and swing area were statistically significant among the three groups. The stride length, walking speed, and step frequency of the vestibular symptom group were lower than those of the non-vestibular symptom group (all P≤0.024). The trunk coronal swing angle of the vestibular symptom group were also larger than those of the non-vestibular symptom group. The results of the CTSIB test showed that the root mean square of coronal plane posture swing and root mean square of sagittal plane posture swing of the vestibular symptom group and the non-vestibular symptom group were larger than those of the control group under four testing conditions, respectively (all P≤0.008). The trunk swing area of the vestibular symptom group was larger than that of the control group under the open eye soft surface testing condition, but smaller than that of the control group under the closed eye soft surface testing condition. There was no statistically significant difference between the vestibular symptom group and the non-vestibular symptom group under four testing conditions (all P>0.05).
Conclusions: Stroke patients with vestibular symptoms have significantly different walking parameters compared to those without vestibular symptoms, which provides important clinical value for implementing targeted rehabilitation treatment.
Walking into the future–Enhancing cognitive diagnosis in vestibular patients using walking task & deep pose estimation
Emilie Lacroix1, Marius Grandjean2, Margaux Huyberechts2, Lucie Steenbergen2, Seyed Abolfazl Ghasemzadeh3, Christophe De Vleeschouwer3, Martin Gareth Edwards4
1Institute for Research in Psychological Science (IPSY), Institute of Neuroscience (IONS), UCLouvain, Louvain- la-Neuve, Belgium; Fund for Scientific Research FNRS, Belgium
2Institute for Research in Psychological Science (IPSY), UCLouvain, Louvain- la-Neuve, Belgium
3ICTEAM/ELEN, UCLouvain, Louvain- la-Neuve, Belgium
4Institute for Research in Psychological Science (IPSY), Institute of Neuroscience (IONS), UCLouvain, Louvain- la-Neuve, Belgium
Purpose: Vestibular disorders impact body orientation, navigation, with varying degrees of affective and cognitive symptoms, reducing patients' quality of life. Previous studies have assessed these effects, usually with extensive and time-consuming physiological and neuropsychological assessment. This study aims to explore the potential of a simple walking task as an indicator of cognitive issues in vestibular disorder patients.
Methods: Sixty-five patients with mixed vestibular disorders, undergoing vestibular physiotherapy, completed a Timed-Up & Go (TUG) task alongside neuropsychological evaluations. Attention was measured using tasks from the Test for Attentional Performance (TAP), while quality of life was assessed through questionnaires. Video recordings of the TUG task were analyzed using a 2D human pose estimation method (OpenTUG) for step count and time taken. Same variables were manually recorded by experimenters for comparison. A control group of thirty average-age matched healthy controls also performed the Timed-Up & Go (TUG) task and the neuropsychological evaluation.
Results: Patients took significantly more time and performed more steps in the TUG task than healthy controls at normal and slow speeds. The observed results were similar between the automatic steps/time derived from OpenTUG relative to steps/time analyses by experimenters, with highly significant correlations. Significant medium to high correlations were detected between cognitive reaction time of alertness measures and the visual subtask of the divided attention TAP task. Significant medium correlations were also present between the DHI and the number of steps/time taken during the TUG task.
Conclusions: These results demonstrated that it is possible to automatically extract pathology-relevant gait parameters using deep pose estimation on 2-D video-recordings of patients with vestibular disorders. The observed relationship between the TUG task and neuropsychological subjective and objective measures demonstrates a need to further explore the feasibility of using a simple walking task combined with pose estimation. It could provide a first line assessment before carrying out extensive neuropsychological evaluation.
13. Imaging of the Inner Ear & Vestibular System
Comparison of Perilymphatic Enhancements Between Gadobutrol and Gadoterate Meglumine in Meniere’s Disease
Tae-Soo Noh1, Jung Sook Joo1, Moo Kyun Park1, Jun Ho Lee1, Ji-Hoon Kim2, In Chan Song2, Myung-Whan Suh1
1Seoul National University Hospital, Department of Otorhinolaryngology-Head and Neck Surgery, Korea
2Seoul National University Hospital, Seoul National University College of Medicine, Department of Radiology, Korea.
Purpose: In this study, we compared the differences in gadolinium contrast agents for endolymphatic hydrops (EH) imaging and quantified the extent of hydrops through MRI-based imaging. The aim was to compare the degree of perilymph enhancement between two gadolinium-based contrast agents (gadobutrol and gadoterate meglumine) in patients with Meniere’s disease (MD) using 3-T MRI.
Methods: Twenty patients were clinically diagnosed with MD based on the criteria of the 2015 Classification Committee of the Barany Society (CCBS). Four hours after intravenous (IV) injection of contrast agents (Gadobutrol (Gadovist, Bayer Ltd., Germany) and Gadoterate Meglumine (Dotarem Guerbet Ltd., France)), we independently measured the signal intensity ratio (SIR) using region of interest analysis and conducted a visual assessment to evaluate the anatomy of the vestibule and cochlea.
Results: The contrast enhancement of the MD side was significantly greater by gadoterate meglumine (44.11±32.18) than by gadobutrol (20.57±14.24, p=0.040) in the vestibule. The contrast enhancement of the MD side was slightly greater by gadoterate meglumine (25.43±12.17) than by gadobutrol (17.97±4.55, p=0.115) in the cochlea. EH% in the vestibule was significantly samller by gadobutrol (37.91±19.79) than by gadoterate meglumine (60.27±21.18, p=0.020). Gadoterate meglumine allowed for a better assessment of the semicircular canals in the vestibule. The contrast effect of gadoterate meglumine (75.96±12.66) seemed to be better than that of gadobutrol (44.20±21.57, p=0.005) in the cochlea.
Conclusions: The inner ear enhancement was significantly greater with gadoterate meglumine than with gadobutrol. Gadobutrol resulted in a low EH% in both the cochlea and vestibule, while the use of gadoterate meglumine led to a higher EH%. Based on these findings, we recommend using gadoterate meglumine instead of gadobutrol for EH imaging.
Contrast-Enhanced MRI of the Inner Ear for Assessing the Blood-Labyrinth Barrier in Meniere’s Disease
Bryan Ward1, Diane Jung1, Yuanqi Sun2, Pogson Jacob3, Jun Hua2
1Johns Hopkins University School of Medicine, Department of Otolaryngology-Head and Neck Surgery, USA
2Johns Hopkins University School of Medicine, Russell H. Morgan Department of Radiology and Radiological Science, Baltimore, USA
3Royal North Shore Hospital, Audiology, Australia
Purpose: We investigate the permeability of the blood labyrinth barrier (BLB) in Meniere’s Disease (MD) patients versus healthy controls using MRI with gadolinium-based contrast agents (GBCA) to identify pathophysiological changes in the inner ear.
Methods: Seven MD patients (n=8 ears) and ten healthy controls (n=20 ears) underwent 3 Tesla MRI scans before and after intravenous Gadoteridol. Dynamic-susceptibility-contrast enhanced scans (DSC) were used to measure GBCA-enhanced signal changes over time in the inner ear (cochlea, vestibule, saccule, and internal auditory canal, IAC). Image analysis used ITK-SNAP for inner ear region segmentation, with statistical analysis conducted via MATLAB and R.
Results: At ∼20s after GBCA, signal changes were detected in all compartments in MD and controls. There were no significant differences between groups in initial GBCA uptake in the cochlea and vestibule. The saccule and IAC exhibited a significantly greater initial signal change in MD (p=0.015), suggesting increased BLB permeability. Over time, the uptake rates aligned between MD patients and controls for the saccule but not the IAC, indicating a temporary increase in permeability that stabilizes in the saccule but ongoing permeability of the IAC. As a group, signal changes were greater at 4 hours for MD than controls, but not for all subjects.
Conclusions: GBCA enters the inner ear shortly after intravenous administration in all subjects. MD patients showed compromised BLB integrity in the saccule and internal auditory canal, with differential gadolinium uptake suggesting variable barrier permeability. Research is needed to explore molecular changes in BLB composition and its clinical implications.
Endolymphatic Hydrops (EH) Imaging with Single-Dose IV Gadolinium
Shinji Naganawa
1
1Department of Radiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
Purpose: FULL TITLE (website restriction too short): Endolymphatic Hydrops (EH) Imaging with Single-Dose IV Gadolinium: Beyond EH.
Endolymphatic hydrops (EH) imaging using single-dose IV gadolinium (Gd) was first reported in 2010. Since then, various technical improvements have been continuously developed, including pulse sequence optimization, image processing, and artificial intelligence reconstruction.
Methods: With IV-Gd method, not only the volume evaluation of EH, but also the evaluation of blood-labyrinthine barrier permeability is possible.
Results: The imaging volume usually includes the brain and orbit. The waste clearance system, i.e., the glymphatic system, is crucial for neurodegeneration of the brain, optic nerve and probably the vestibulocochlear nerve.
Conclusions: This presentation will also include the potential of the IV-Gd method for evaluation of the glymphatic system.
Endolymphatic hydrops asymmetry distinguishes Meniere's disease with high sensitivity and specificity
Tae-Soo Noh1, Moo Kyun Park1, Jun Ho Lee1, Seung Ha Oh1, Ji-Hoon Kim2, In Chan Song2, Myung-Whan Suih1
1Department of Otorhinolaryngology-Head and Neck Surgery, Seoul National University Hospital
2Department of Radiology, Seoul National University Hospital
Purpose: Many endolymphatic hydrops (EH) MRI studies in the literature do not include a normal control group. Consequently, it remains unclear which outcome measure in EH MRI can most effectively distinguish between MD patients and normal controls.
Methods: Gadolinium-enhanced EH imaging was performed to quantitatively evaluate the extents of hydrops in MD patients and age-/sex-matched normal controls. Four hours after intravenous injection of contrast agent, MRI was performed using a 3-T MR platform fitted with a 32-channel phased-array coil receptor. MR images (10-15 slices) covering an inner ear were 3D-stacked. Analyses of all images that included the vestibule or the cochlea yielded the volumes (in μL) of the endolymphatic and perilymphatic spaces.
Results: For the vestibule, they were significantly greater EH% in ipsilateral (52.4 ± 12.5) than in contralateral MD ears (40.4 ± 8.5, p = 0.001) and in ipsilateral MD ears than in control ears (42.4 ± 13.7, p = 0.025). For the cochlea, the values were slightly higher EH% in ipsilateral MD ears (49.7 ± 10.4, p = 0.061) but did not significantly differ from contralateral (41.3 ± 12.6) or control ears (39.6 ± 18.9, p = 0.858). In the MD group, the EH asymmetries were 12.0 ± 10.2% (vestibule) and 8.4 ± 8.6% (cochlea), significantly larger than those of controls.
Conclusions: Compared to conventional semiquantitative grading or quantitative EH% analysis, EH asymmetry may better distinguish MD patients from normal controls. Quantitative hydrops volumetric analysis yields clinically relevant information on inner ear function.
Intratympanic gadolinium MRI to detect endolymphatic hydrops
Jing Zou1, Luguang Chen1, Hongbin Li1, Zikai Zhao1, Guoping Zhang1, Jianping Lu1, Ilmari Pyykkö2
1Department of Otolaryngology-Head and Neck Surgery, Center for Otolaryngology-Head & Neck Surgery of Chinese PLA, Changhai Hospital, Second Military Medical University, Shanghai, China
2Department of Otolaryngology, Tampere University, Finland
Purpose: FULL TITLE (website restriction too short): Intratympanic gadolinium MRI to detect endolymphatic hydrops and trace passage of therapeutics into the inner ear of patients with Meniere’s disease.
A better visualization of endolymphatic hydrops (EH) can be achieved with intratympanic administration of gadolinium (Gd-DTPA) than intravenous injection regarding the enhancement efficacy and potential adverse effects in MRI. Intratympanic administration also allows to determine the efficacy of intratympanic therapy of Meniere’s disease (MD) and passage of the therapeutics, as dexamethasone (Dex) into the inner ear.
Methods: One hundred fifty-one MD patients were involved in the study. MRI was performed using 3.0 T equipment 24 h after intratympanic injection of low-dose Gd-DTPA. A novel protocol of heavily T2-weighted 3-dimensional fluid-attenuated inversion recovery reconstructed with magnitude and zero-filled interpolation (hT2W-FLAIR-MZFI) was optimized and validated in 27 MD patients. The potential impact of Gd-DTPA on the stability of dexamethasone was evaluated in vitro. The interference of Dex on MRI visualization of EH was analyzed in 10 patients with definite MD. The final protocol of EH MRI using hT2W-FLAIR-ZFI after intratympanic injection of low-dose Gd-DTPA mixed with Dex was tested in 114 MD patients.
Results: Dex does not interfere with the degree of EH in MD patients
Conclusions: MRI using hT2W-FLAIR-MZFI 24 h after intratympanic injection of Gd-DTPA mixed with Dex enables a simplified fast detection of EH in MD patients with high-quality images and allows to trace the passage of Dex into the inner ear.
INTRODUCTION
Robert Gürkov
1
1ENT Centre Red Cross Square, University of Munich, Germany
Purpose: Menière's Disease (MD) is one of the most common vestibular disorders and one of the most common inner ear disorders. It is defined as the syndrome of endolymphatic hydrops (ELH). There is no curative therapy available and clinical therapeutic trials in patients with a certain diagnosis are urgently needed. Diagnosis in living patients had to rely on the history of typical symptoms in the past, because hydrops could only be confirmed post-mortem. More than a decade ago, a revolutionary innovation was achieved: The in-vivo visualization of ELH by MR imaging. Since then, endolymphatic hydrops imaging (EHI) is used worldwide increasingly in the diagnosis of MD and in clinical research. A large variety of contrast application techniques, dosages, MR scanning hardware and parameters are being used. The increasing body of evidence supports the central role of ELH in the pathophysiology of Hydropic Ear Disease. For the first time in history, the diagnosis is being confirmed by the pathology and the symptomatic manifestations are being re-defined, revealing a broad spectrum of audiovestibular symptoms beyond the former clinical diagnostic criteria, and the concept of Hydropic Ear Disease has been developed, which unites all symptomatic variations and the primary and secondary forms under one roof.
Methods: This symposium is of interest to all clinicians and researchers concerned with Hydropic Ear Disease. The audience will receive first-hand information from pioneers of endolymphatic hydrops imaging.
Results: The speakers from independent research teams from four different countries will present the latest state-of-the art innovations from intravenous contrast enhanced EHI and from intratympanic contrast enhanced EHI.
Conclusions: They will present a novel grading system for EHI and novel insights into the longitudinal in-vivo evolution of Hydropic Ear Disease as well as correlation studies between ELH and clinical symptoms, all of which are crucial for our understanding of Hydropic Ear Disease.
MRI of Endolymphatic Hydrops in Ménière's Disease
Rita Sousa1, M Lobo2, H Cadilha1, T Eca3, Leonel Luis3
11. Neuroradiology Department, Hospital Santa Maria, Centro Hospitalar Lisboa Norte, Lisbon, Portugal. 2. Imagiology Department, Faculty of Medicine of Lisbon, Lisbon, Portugal
2Faculty of Medicine of Porto, CINTESIS@RISE, MEDCIDS, University of Porto, Porto, Portugal
3Otorhinolaryngology Department, Centro Hospitalar Lisboa Norte, Lisbon, Portugal.
Purpose: FULL TITLE (website restriction too short): MRI OF ENDOLYMPHATIC HYDROPS IN MÉNIÈRE'S DISEASE: TRANSVERSAL AND LONGITUDINAL EVALUATION.
Endolymphatic hydrops is universal in Ménière's disease (DM). Given its chronic course, with variable times for the onset of the complete clinical picture of DM according to current criteria, it seems relevant to understand the progression of endolymphatic hydrops and disruption of the blood-perilymphatic barrier in patients with DM and in monosymptomatic conditions.
Methods: 239 consecutive patients were referred for suspected hydropic ear disease. 50 individuals agreed to participate in the study - the final sample of the longitudinal study included 24 patients (7 D1, 7 D2, 10 D3). The control group included 10 patients. At recruitment, clinical and MRI reassessment (3 tesla, intravenous technique) was performed (MRI2) and 2 years later the MRI was repeated (MRI3). Previous MRI (MR1) was assessed retrospectively.
Patients were classified as definitive (D1), possible (D2) and monosymptomatic (D3) DM. The control group included symptoms not characteristic of DM (C2/C3) and 6 asymptomatic patients (C1). The vestibular endolymphatic ratio (vER), the degree of vestibular hydrops, presence/absence of cochlear hydrops, cochlear perilymphatic enhancement asymmetry and vER progression rate were evaluated by two independent neuroradiologists and compared between the patient and control groups (index ear).
Results: Endolymphatic hydrops was universal and pronounced on D1, remaining stable. The progression of vER was more variable and pronounced in some D3 (worse in the index ear) and in D2 (non-index) patients, although these observations were not statistically significant.
Conclusions: Considering that many presentations of probable and monosymptomatic DM evolve years later into definitive DM and that DM tends to be bilateral, these findings may translate into a tendency for an accelerated initial worsening of endolymphatic hydrops in earlier stages of the disease, to be confirmed in controlled studies with larger samples.
The hybrid grading system in MR hydrops imaging
Bert De Foer1, Anja Bernaerts1
1Department of Radiology, GZA Hospitals, Antwerp, Belgium
Purpose: MR hydrops imaging has emerged as the primary imaging tool for the evaluation of primary and secondary hydropic ear disease the past one and a half decade.
Methods: Hydrops imaging is still mainly performed using contrast administration as the non-contrast techniques still have inconsistent results. Most literature handles on delayed intravenous post gadolinium administration versus the less frequently used intratympanic gadolinium administration. Most frequently used MRI sequences are either 3D space-flair sequences, either 3D real-IR sequences, performed on 3T MR machines 4 hours after a single dose of iv gadolinium.
Results: A recent metanalysis of hydrops imaging literature has demonstrated that the combination of a 3-grade cochlear grading system and a 4-grade vestibular grading system together with the evaluation of increased peri-lymphatic enhancement -the so-called hybrid grading system- yields the highest diagnostic accuracy for the detection of patients with definite Menière’s disease.
Conclusions: It moreover potentially has the capability of differentiating Menière’s disease from vestibular migraine.
Unraveling the Vestibular Cortical Network: Insights from Intracranial Electrical Stimulation in Epileptic Patients
Christophe Lopez1, Zoé Dary1, Stanislas Lagarde2, Samuel Medina Villalon2, Hugo Dary3, Elodie Garnier4, Jacques Léonard1, Fabrice Bartolomei2
1French National Center for Scientific Research (CNRS) & Aix Marseille University, Marseille, France
2Epileptology and Cerebral Rhythmology Department (member of the ERN EpiCARE Network), APHM, Timone Hospital, Marseille, France
3Aix Marseille Univ, CNRS, Center for Magnetic Resonance in Biology and Medicine (CRMBM), Marseille, France
4Institut de Neurosciences des Systèmes, Aix Marseille University, INSERM, Marseille, France
Purpose: A broad cerebral network processing vestibular information has been described in the human brain. Most studies have employed functional neuroimaging approaches, which have provided indirect and correlative descriptions of the vestibular cortex. Causal approaches can be provided by intracranial electrical brain stimulation (EBS) in epileptic patients and analysis of functional connectivity changes in brain networks
Methods: We conducted a retrospective analysis of responses induced by EBS in 354 patients diagnosed with refractory partial epilepsy (176 females; mean age 26 ± 14 years) who underwent invasive stereoelectroencephalography between 2000 and 2021. Among them, 49 patients had electrodes implanted exclusively in the left hemisphere, 40 in the right hemisphere, and 265 bilaterally. Our analysis encompassed a total of 19,654 EBS, from which 2,197 responses were elicited by high-frequency EBS (mean intensity 1.4 ± 0.6 mA). First, we conducted functional mapping of vestibular sensations by analyzing the locations of EBS. Second, we examined changes in functional connectivity between distant electrode contacts by analyzing stereoelectroencephalography signals at the time of vestibular sensations induced by EBS.
Results: We identified 55 patients experiencing vestibular sensations following EBS (such as dizziness, vertigo, swaying, sensation of floating or rising in the air, feelings of rotation, and falling). These sensations were predominantly reported after EBS targeting the ventral posterior cingulate cortex, precuneus, anterior cingulate cortex, insula, amygdala, and superior temporal neocortex. Functional connectivity analysis revealed significantly higher node strength in the insular cortex associated with self-motion illusions (excluding unspecific vertigo/dizziness sensations), along with increased connectivity with the amygdala, hippocampus, superior temporal sulcus, and middle temporal cortex.
Conclusions: The current findings contribute to the comprehension of the multisensory vestibular cortical network utilizing an approach regarded as a gold standard for demonstrating the causal implications of cerebral networks in sensorimotor functions.
14. Meniere’s Disease and Related Disorders
Analysis of patients with severe Ménière’s disease; should we wait?
Floris Gerritsen1, Annejet Schenck1, Heiko Locher2, Raymond van de Berg3, Peter Paul van Benthem4, Henk Blom5
1Department of Otorhinolaryngology and Head & Neck Surgery, Leiden University Medical Center, Leiden, The Netherlands/HagaHospital The Hague
2Department of Otorhinolaryngology and Head & Neck Surgery, Leiden University Medical Center, Leiden, The Netherlands/The Novo Nordisk Foundation Center for Stem Cell Medicine (reNEW), Leiden University
3Division of Balance Disorders, Department of Otorhinolaryngology and Head and Neck Surgery, Faculty of Health Medicine and Life Sciences, School for Mental Health and Neuroscience, Maastricht Universi
4Department of Otorhinolaryngology and Head & Neck Surgery, Leiden University Medical Center, Leiden, The Netherlands
5Department of Otorhinolaryngology and Head & Neck Surgery, Leiden University Medical Center, Leiden, The Netherlands/HagaHospital The Hague/Antwerp University Hospital
Purpose: The course of vertigo attacks in Ménière’s disease (MD) has been studied but results are ambiguous. However, knowledge of this topic may affect treatment choice. We aim to assess course of complaints among a group of patients with severe Ménière’s disease.
Methods: This is a retrospective cohort study in a Ménière’s disease expert center. Patients with definite unilateral Ménière’s disease and persisting vertigo attacks despite treatment with intratympanic steroid injections were included. All patients had been waitlisted for participation in a planned trial assessing non-ablative surgical intervention, but did not undergo this surgical intervention because recruitment for the trial had not started yet. In September 2022, data collection from patient’s files and follow-up telephone interviews were conducted. Primary outcome measure is the proportion of patients with sufficient vertigo control. Among secondary outcome measures were duration of disease and hearing, and a subgroup analysis (surgery vs. conservative treatment) was performed.
Results: Thirty-five patients (54% male, mean age of onset 52 years, 51% right sided) were included in the analysis. Of the 33 patients with complete information on vertigo attacks, 21 (64%) were free of vertigo attacks after a median disease duration of 5.3 years. Twenty-six of the 35 waitlisted patients (74%) no longer wished to undergo surgery.
Hearing of the affected ear declined over time (n=29, p=.006). The patients who underwent surgery had longer duration of disease and more visits to their ENT-surgeon.
Conclusions: Even in a population with severe Ménière's disease, most patients will have sufficient control of vertigo; most will be free of vertigo attacks eventually. This is important information when considering treatment options, and raises the question if ablative treatment should even be performed.
ASSESSMENT OF VESTIBULO-MASSETERIC REFLEX PATHWAYS IN INDIVIDUALS WITH MENIERE’S DISEASE
Kalaiyarasan Ravichandran1, Sujeet Kumar Sinha2
1Junior Research Fellow, Department of Audiology, All India Institute of Speech and Hearing, Mysuru, Karnataka, India
2Associate Professor, Department of Audiology, All India Institute of Speech and Hearing, Mysuru, Karnataka, India
Purpose: In recent days, Masseter Vestibular Evoked Myogenic Potential (mVEMP) re-captivated the researcher’s interest to explore the response parameters. mVEMP assessing the functional integrity of vestibulo-masseteric reflex (VMR) pathway. It also has remarkable value in diagnosing brainstem lesion in individuals with various neurodegenerative disorders. So, this study aimed to assess the VMR pathway in individuals with Meniere’s disease.
Methods: Group I included with twenty individuals (14 males, six females) with unilateral definite Meniere’s disease (11 right ear affected, 9 left ear affected). Group II included with healthy controls (10 males, ten females). mVEMP was recorded using 500 Hz tone burst (2-0-2 cycles) at a rate of 5.1/s with an intensity level of 125 dBpeSPL for ipsilateral, contralateral and binaural modes of stimulation. Inverting electrode was placed at the zygomatic arch, non-inverting at the lower third of masseter belly tendon, and ground at lower forehead.
Results: mVEMP response parameters were analysed for both group I and II. mVEMP was present in 9 individuals with right affected Meniere’s and 8 individuals with left affected Meniere’s. Mann-Whitney U test showed a significant difference (p<0.05) for latency (p11,n21) and rectified amplitude (p11-n21) parameters between Meniere’s affected ears and healthy controls for ipsilateral p11 (Z=2.83, p=0.00), n21 (Z=3.17, p=0.00); p11-n21 (Z=4.73, p=0.00); contralateral p11 (Z=2.44, p=0.01), n21 (Z=2.82, p=0.00); p11-n21 (Z=4.23, p=0.00); binaural p11 (Z=3.69, p=0.00), n21 (Z=3.46, p=0.00); p11-n21 (Z=4.84, p=0.00).
Conclusions: The results of the study revealed a significant difference for mVEMP response parameters between Meniere’s affected ears and healthy controls for ipsilateral, contralateral and binaural modes of stimulation.
Can Head Sway Patterns Differentiate between Patients with Meniere’s Disease vs. Peripheral Vestibular Hypofunction?
Jennifer Kelly1, Maura Cosetti1, Anat Lubetzky2
1New York Eye and Ear Infirmary of Mount Sinai, New York, NY, USA
2New York University, New York, NY, USA
Purpose: Due to the variable clinical presentation of Meniere's disease (MD), objective tests of MD may have significant diagnostic utility. We investigated whether head sway can differentiate between patients with MD, vestibular hypofunction (VH) and healthy controls.
Methods: 80 adults (30 healthy controls, 32 with VH, and 18 with MD) were recruited from a tertiary vestibular clinic. All underwent a postural control assessment using the HTC Vive Pro Eye HMD that recorded head sway in the anterior-posterior (AP), medio-lateral (ML), pitch, yaw and roll direction. Participants were tested with 2 levels of visual load: a static versus oscillating star display. Each scene lasted 60 seconds and was repeated twice. Sway in each direction was quantified using root mean square velocity (VRMS) for the first 20 seconds and full 60 seconds of each scene.
Results: Static visual: participants with VH showed significantly larger head VRMS than controls in the AP (60 seconds and 20 seconds) and pitch (20 seconds) directions. Dynamic visual: participants with VH showed significantly larger head VRMS than controls all directions for both the 60 and 20 second analysis. Participants with MD did not differ significantly from the control or the VH group.
Conclusions: While limited in numbers, Patients with MD had a high variability in head sway in all directions, and their average head sway was between controls and those with VH. The similar finding between 20- and 60-seconds scene, its sensitivity to VH and the full portability of the system with an in-clinic testing setup could help these future endeavors.
Changes in Absorbance in Wideband Tympanometry with Endolymphatic Sac Shunt Surgery for Meniere's Disease
Masafumi Ohki1, Tomomi Horikoshi1, Sunao Tanaka1, Shigeru Kikuchi1
1Saitama Medical Center, Saitama Medical University, Department of Otolaryngology, Japan
Purpose: Meniere's disease is often treated with various therapies including dietary measures or medications. Some patients, however, are refractory and are treated with endolymphatic sac shunt surgery. It has been reported to be effective in controlling vertigo, but the mechanism remains unclear. In wideband tympanometry, 1-power reflectance is referred to as absorbance, Vibration properties of the middle or inner ear have some influence on the absorbance. It has been reported that endolymphatic hydrops may alter vibration properties, and the efficacy of wideband tympanometry is being investigated. We will examine how the endolymphatic sac shunt surgery performed for refractory Meniere's disease alters the absorbance.
Methods: Patients with refractory Meniere's disease who underwent endolymphatic sac shunt surgery at our department were enrolled in this study. Absorbance was measured at a continuous frequency range of 226-8000 Hz.
Results: Absorbance measured by wideband tympanometry exhibited an M shape change before and after endolymphatic sac shunt surgery. Frequency range with M shape absorbance was changed.
Conclusions: Continuous frequency absorbance measurements by wideband tympanometry suggest that frequency properties can be altered by endolymphatic sac shunt surgery. It may indicate that Endolymphatic sac shunt surgery can be practically influential on alteration of endolymphatic hydrops.
Clearing complexity – re-framing Meniere's Disease in the genomic era
Stephen Spring1, William Gibson2
1MRFI, Sydney University, Formerly VP, now disbanded
2Sydney University
Purpose: Gibson suggests vertigo from Reissner’s Membrane rupturing implausible. Bast’s Valve opening under Endolymph Longitudinal Flow (ELF) is much more likely, implying reduced Endolymph (E) clearance capacity is essential for Endolymphatic Hydrops (EH). The presenter suggests phenotypical subsets within clinical/animal studies via systemic, immunogenetic, metabolic and redox pathways to unify Gibson's explanation - EH is multiple pathologies interfacing genetics and immunological dysfunction.
Methods: Various antigen routes access Scala Media (SM). The Endolymphatic Sac (ES) is immunocompetent. ELF is a micro-inflammatory response, shifting antigen “off-site” to ES for homing lymphocytes, MALT cells and macrophage enzymes. Immune complexe(s) (IC) in ELF and IC deposits in ES basement membranes create fibrosis and impair E clearance. Bone dysplasia narrows the duct reducing capacity. Human histological hallmarks are replicable in animals with hypoxic, genetic, diet, lifestyle, allergic, viral and anatomical variants. SM is immune privileged locally, but EH systemically blunts inflammatory cells to preserve hair cells under ELF. Splenic and thymus phases exist in eyes (ACAID) and probably SM, shifting systemic cytokine and cell profiles to bias TH1 to TH2 and IC overproduction. MD associates with systemic, autoimmune and IC pathologies such as SLE.
Results: Barany correctly classifies clinical EH. Emerging familial and rarer genotypes omits sporadic, heterogeneous EH. SNP variants in many pathways confer susceptibility to EH such as 8.1, a Eurocentric haplotype prone to autoimmunity, reduced processing of virus, variation of C4 synthesis/fixation and solubilised ICs. Future genetic architecture will include sporadic subsets.
Conclusions: EH occurs with excess E relative to an individual's E processing capacity. It's not one disease. Immune response is genetic and opens new possibilities to genetically identify subsets. Immunogenetics reveal numerous MD genes without a gene explaining sporadic MD. The presenter opens discussion for a ‘immuno and genotype analysis first’ for precision, personal treatment. A one-size-fits-all approach is too simplistic and needs re-thinking.
Combining Audio-vestibular Tests and Vertigo for Menière’s Disease Severity Evaluation: Towards a Novel Grading Proposal
Hui Wang1, Shujian Huang1, Junjie Guo1, Jiayu Li1, Haibo Shi1, Shankai Yin1
1Shanghai Sixth People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Department of Otorhinolaryngology-Head and Neck Surgery, China
Purpose: We aimed to combine a battery of audio-vestibular tests and vertigo episodes to evaluate severity of Menière’s Disease (MD), thereby advancing a proposal for a novel grading of MD.
Methods: Vestibular organs involvement (VOI) was assessed through vestibular-evoked myogenic potentials (VEMPs), the video head impulse test (vHIT), and the rotary chair test (RCT). Vertigo severity was quantified utilizing Dizziness Handicap Inventory (DHI) scores and vertigo episodes frequency. Pure-tone audiometry (PTA) was applied to evaluate hearing impairment. Subsequently, machine learning (ML) models were employed to identify significant variables. Cluster analysis, based on VOI, PTA, and vertigo episodes frequency, was conducted to categorize individuals into subtypes.
Results: Among 101 patients, saccular hypofunction correlated significantly with elevated DHI scores (r = 0.31, P = 0.001) and increased vertigo frequency (r = 0.27, P = 0.007). The significant predictors for DHI in ML models included RCT, anterior-canal vHIT, cervical VEMP, and vertigo episodes, eventually identified by Genetic Algorithm-Neural Network (R2 = 0.906). A five-cluster fitted the data best. Cluster1 (27.72%) demonstrated the PTA <45 and VOI <3, whereas those in Cluster4 (23.76%) presented with PTA ≥45 and VOI ≥3. Particularly, patients in Cluster5 (6.93%) experienced vertigo attacks predominately, with exceeding 20 occurrences annually. Among 25 patients followed-up post 18 to 24 months of treatment, 60% (3/5) in Cluster1 and 71% (5/7) in Cluster2 achieved control, whereas only 50% (2/4) in Cluster3.
Conclusions: Stratifying MD patients into 5 subtypes integrated audio-vestibular tests outcomes and vertigo episodes to estimate disease progression may facilitate personalized early interventions.
cVEMP responses differ for Meniere’s disease with and without coexisting headaches
Takaki Inui1, Kou Moriyama1, Yusuke Ayani1, Akiko Ozaki1, Yuko Inaka1, Shin-ichi Haginomori1
1Department of Otorhinolaryngology – Head & Neck Surgery, Osaka Medical and Pharmaceutical University, Japan
Purpose: Meniere’s disease (MD) and headaches, especially migraine often coexist. The present study aimed to elucidate the differences between the cases of MD with and without coexisting headaches.
Methods: Fifteen patients with definite unilateral MD without headaches (MD/H-) and 20 patients with definite unilateral MD with headaches (MD/H+; 15 cases of migraine without aura and 5 cases of suspected migraine or tension-type headache) were enrolled. The medical records, results of vestibular examinations in monothermal caloric test and cervical vestibular evoked myogenic potential (cVEMP) of the patients were reviewed.
Results: The patients in the MD/H- group were predominantly male (p = 0.004). In the MD/H+ group, the frequency of vertigo and the DHI values were significantly higher than those in the MD/H- group (p = 0.045, < 0.001, respectively). The caloric testing results were abnormal for 10 of the 13 MD/H- cases, and 14 of the 16 MD/H+ cases, which revealed no significant difference between both groups. The cVEMP testing revealed positive saccular dysfunction based on the asymmetry ratio of 4 of the 15 MD/H- cases, and 14 of the 20 MD/H+ cases; it was significantly more prevalent in the MD/H+ group than in the MD/H- group (p = 0.018).
Conclusions: Most of the headaches confirmed in MD were migraine and MD/H- showed a significant male preponderance. Concomitant headache may affect the manifestations of the saccular function in MD cases.
Developing a core outcome set for future Randomized Controlled Trials in Menière's Disease
Maud Boreel1, Babette van Esch1, Raymond van de Berg2, Peter Paul van Benthem1, Tjasse Bruintjes1
1Leiden University Medical Center, Otorhinolaryngology, Head and Neck surgery, the Netherlands
2Maastricht University Medical Center, Otorhinolaryngology, Head and Neck surgery, the Netherlands
Purpose: A standard guideline on selecting outcome measurements used in clinical trials on the treatment of Menière's disease (MD) is missing. Inadequate selection and inconsistency of outcome measures in trials compromises the quality and relevance of trial results and complicates the comparison of results. A core outcome set (COS) suggests a minimal amount of data that ought to be measured and reported in each clinical trial for a particular condition. In this study, we aim to propose a COS for Randomized Controlled Trials (RCTs) on the treatment of MD following the steps of the protocol described by the COMET handbook and the COSMIN initiative.
Methods: The development of a COS involves multiple steps: 1) identifying existing knowledge through a scoping review and a patient focus group meeting; 2) executing two global Delphi procedures, involving multiple stakeholders to achieve consensus on COS outcome domains, outcome measurements and outcome measurement instruments (OMIs) to be used in the COS; 3) assessing the methodological quality of each OMI; and 4) conducting a final consensus meeting.
Results: To date, we conducted a systematic review of randomized controlled trials evaluating treatment effects in MD from 2006 to 2023. We have included 35 RCTs and found considerable variability in the use of outcome measures and OMIs. In addition, these outcome measures and OMIs were not standardized and often not validated.
Conclusions: The first step of the development of a COS for MD revealed that there is considerable variability in outcome measures used in RCTs on MD, the next step is to convene a patient focus group meeting and initiate the first Delphi procedure.
DIRECTION OF NYSTAGMUS DURING MENIERE’S CRISIS. CONTRIBUTION OF A MOBILE PHONE. PHYSIOLOGICAL IMPLICATIONS
Pierre Bertholon1, Tamadhor Alzarqaa1, Alexandre Karkas1
1Saint Etienne, University Hospital, France
Purpose: Spontaneous nystagmus during vertigo attacks of Menière’s syndrome has been essentially described as horizontal, beating ipsilaterally (irritative type) or controlaterally (deficit type) to the hearing loss.
Our main objective was to describe the characteristics of nystagmus during vertigo attacks. The second objective was to determine the feasibility of self-video recording of eye movements by a mobile phone.
The third objective was to discuss the clinico- physiological implications of the observed nystagmus.
Methods: We selected patients with definite Meniere’s disease according to the Barany Society.
Patients were video recorded during their attacks either by videonystagmoscopy by the physician or by a mobile phone.
Results: Sixteen patients were video-recorded either by mobile phone (n = 9) or videonystagmoscopy (n = 7).
The nystagmus was horizontal in 13 patients either of the irritative (n= 7) or deficit type (n = 6).
The nystagmus was vertical in 3 patients, either down beating (n = 2) or up beating (n = 1). This vertical nystagmus changed to a more classical horizontal nystagmus in 2 patients.
Conclusions: The direction of the nystagmus is mostly horizontal although it can be vertical.
This nystagmus can be video-recorded by a mobile phone, which is an objective proof of the impact on daily life.
The observation of an initial vertical nystagmus which change to a more classical horizontal in 2 patients could be explained by a spreading of the mechanism from the vertical to the horizontal canal and suggest a mobile phenomenon in the inner ear of Meniere’s syndrome
Early Experience With Long-Acting Dexamethasone For Precise Delivery to the Round Window Membrane for Meniere's Disease
Jeffrey Sharon1, Jafri Kuthubutheen2, Benson Jung3, Jia Ng4, Hugo Peris3, Eugene De Juan3, Charles Limb1
1University of California, San Francisco, Department of Otolaryngology-Head and Neck Surgery, USA
2University of Western Australia, Department of Surgery, Australia
3Spiral Therapeutics, Inc., USA
4Singapore General Hospital, Department of Otorhinolaryngology-Head and Neck Surgery, Singapore
Purpose: To Investigate the safety and feasibility of precise delivery of long acting gel formulation containing 6% dexamethasone (SPT-2101) to the round window membrane for the treatment of Meniere’s disease.
Methods: This is a prospective cohort study conducted at a tertiary care vestibular clinic. Eligible subjects were adults aged 18 to 85 with a diagnosis of unilateral definite Meniere’s disease per Barany society criteria. They were treated with single injection of SPT-2101 under direct visualization into the round window niche, or a placebo. Procedure success rate, adverse events, and vertigo control were assessed. Vertigo control was measured with Definitive Vertigo Days (DVDs), defined as any day with a vertigo attack lasting 20 minutes or longer.
Results: The first 10 subjects were treated with SPT-2101, and the next 6 (recruitment is ongoing) were treated with either SPT-2101 (n=3) or placebo (n=3), with an option to crossover. Precise placement of SPT-2101 at the round window was achieved in all subjects with in-office microendoscopy. Adverse events included one tympanic membrane perforation, which healed spontaneously after the study, and two instances of otitis media, which resolved with antibiotics. The average vertigo days per month for SPT-2101 was 17.7 during the baseline month, decreasing to 9.4 by month 1, 6.7 by month 2, and 4.2 by month 3 (N=15). In the three subjects treated to date, placebo was not effective.
Conclusions: SPT-2101 delivery to the round window is safe and feasible, with early results indicating good vertigo control.
Electroencephalography Microstate Signatures of Ménière’s Disease
Yi-Ni Li1, Wen Lu1, Jie Li1, Peng-Jun Wang1, Dong-Zhen Yu1, Hui Wang1, Zheng-Nong Chen1, Hai-Bo Shi1, Shan-Kai Yin1
1Department of Otolaryngology-Head and Neck Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine
Purpose: To explore the microstate characteristics of Ménière’s disease (MD) based on high-density electroencephalography (EEG), elucidate the temporal dynamics of their brain network activity, and explore the potential of EEG microstate features as future functional biomarkers for MD.
Methods: Thirty-two patients diagnosed with MD and 29 healthy controls (HC) matched for demographic characteristics were included in the study. Dysfunction and subjective symptom severity were assessed by neuropsychological questionnaires, pure tone audiometry, and vestibular function tests. Resting-state EEG recordings were obtained using a 256-channel EEG system, and the electric field topographies were clustered into four dominant microstate classes (A, B, C, and D). The dynamic parameters of each microstate were analyzed and utilized as input for a support vector machine (SVM) classifier to identify significant microstate signatures associated with MD. The clinical significance was further explored through Spearman correlation analysis.
Results: Patients with MD exhibited increased presence of microstate Class C and decreased transitions between microstate Class A and B. The transitions between microstate Class A and C were elevated in MD. Utilizing the microstate features identified via sequential backward selection, the linear SVM classifier achieved a sensitivity of 89.66% and a specificity of 87.5% in distinguishing MD patients from HC. Further analysis revealed a positive correlation between vertigo symptoms and the occurrence of microstate Class C (R=0.461, P<0.001), and transitions between Class A and B were negatively correlated with vertigo symptoms (R=-0.55, P<0.001; R=-0.59, P<0.001). Interestingly, no significant correlations were detected between these characteristics and objective vestibular or auditory test results.
Conclusions: We identified several EEG microstate features in MD patients, which can effectively discriminate them from HC and correlate with subjective severity rather than clinical tests, suggesting a potential contribution of brain network alterations to clinical diversity. Microstate features may serve as a new direction for exploring potential neurobiological markers of MD.
Endolymphatic Sac Hypoplasia in Menière’s Disease: A Predisposing Factor for Cochlear Implantation
Catrin Brühlmann1, Julia Dlugaiczyk1, Adrian Dalbert1, Dorothe Veraguth1, Christof Röösli1, Alexander Huber1, Amy F. Juliano2, Andreas H. Eckhard3, David Bächinger1
1Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Zurich, Zurich, Switzerland
2Department of Radiology, Mass Eye and Ear, Boston, USA
3Otopathology Laboratory, Department of Otolaryngology, Mass Eye and Ear; Department of Otolaryngology, Harvard Medical School, Boston, USA
Purpose: Menière's disease (MD) is characterized by progressive sensorineural hearing loss over the long term, with varying dynamics and severity among patients. Approximately 10% of MD patients eventually experience profound hearing loss with candidacy for cochlear implantation (CI) to restore serviceable hearing. In this study, we investigated predisposing factors for profound hearing loss and the need for CI in MD patients. We focused on two previously defined 'disease endotypes' distinguished radiologically by either a hypoplastic endolymphatic sac (subgroup MD-hp) or degenerated endolymphatic sac (subgroup MD-dg).
Methods: Retrospective two-center cohort study. Inclusion criteria for “CI MD-cohort”: Definite MD (Bárány Society, 2015) and history of uni- or bilateral CI between 2002 and 2023. Inclusion criteria for “control MD-cohort”: Definite MD (Bárány Society, 2015), and consecutively enrolled from 2010 to 2015. In both cohorts, patients were stratified according to endotype (MD-dg or MD-hp), using an established temporal bone CT imaging criterion, the “angular trajectory of the vestibular aqueduct.” The endotype ratios (MD-hp : MD-dg) between the two cohorts were statistically compared.
Results: The endotype ratio in the CI MD-cohort (51 patients; mean age 64.5 years, SD 12.2) was 65%:35% (MD-hp:MD-dg) and in the control MD-cohort (72 patients; mean age 43.1 years, SD 12.0) 24%:76% with a significant difference between cohorts (p<0.0001; odds ratio 5.9).
Conclusions: The patient subgroup MD-hp demonstrates a significantly higher prevalence of CI, being 5.9 times more common compared to the subgroup MD-dg. Consequently, endolymphatic sac hypoplasia emerges as a potential risk factor for severe hearing loss and candidacy for CI within the broader MD population. Since the endotype can be diagnosed at the onset of MD, often years to decades before hearing loss reaches profound levels, endotyping MD patients holds promise for personalized patient counseling, tailored audiological follow-up planning, and informed clinical decision-making regarding CI.
Long-term efficacy of endolymphatic duct blockage in 65 cases of Meniere disease
Daogong Zhang1, Yafeng Lyu1, Zhaomin Fan1, Haibo Wang1
1Department of Otolaryngology-Head and Neck Surgery, Shandong Provincial ENT Hospital, Shandong University, Jinan, Shandong, China
Purpose: This study was aimed to explore the efficacy of endolymphatic duct blockage(EDB) in the treatment of intractable Meniere’s disease (MD).
Methods: Sixty-five unilateral MD patients, who were treated with EDB in our hospital between Jan. 2013 and Dec.2020, were recruited in this study for retrospective analysis. Vertigo control and auditory function were monitored during at least two-years follow-up. Pure tone audiometry, caloric test, vestibular evoked myogenic potential (VEMP) were performed in two-year follow-up.
Results: The total control rate of vertigo was 83.1% (54/65), with complete control rate of 63.1% and substantial control rate of 20.0%. The rate of hearing loss was 13.8%. No patient incurred complications after the surgery, such as infection, facial paralysis, or cerebrospinal fluid leakage.
Conclusions: Endolymphatic duct blockage (EDB), which can reduce vertiginous symptoms in patients with intractable Meniere's disease (MD), represents an effective therapy for this disorder.
Menière's Disease and Vestibular Migraine: differential diagnosis and overlappings
Roberto Carlo Teggi1, Michael von Brevern2, Julia Dlugaiczyk3, Augusto Pietro Casani4
1IRCCS Ospedale San Raffaele, Milano, Italy
2Neurologisches Zentrum, Berlin, Germany
3Klinik für Ohren-, Nasen-, Hals- und Gesichtschirurgie & Interdisziplinäres Zentrum für Schwindel und neurologische Sehstörungen, Universitätsspital Zürich (USZ), Universität Zürich (UZH), Rämistrasse
4Italia
Purpose: The differential diagnosis between Menière's Disease (MD) and Vestibular Migraine (VM) is often a puzzling dilemma in the early stages, and in some cases mainly rely on an audiometric exam, although new imaging thechniques may demonstrate hydrops in the inner ear. Moreover, a high rate of MD subjects also suffer from migrainous headache.
Recent papers finally focus on the possibility that MD subjects may have also non hydropic attacks, possibly due to VM.
The purpose of the round table is to summarize what is known on differential diagnosis and overlap of these two episodic vertigo.
The authors propose a round table on Vestibular Migraine and Menière's Disease, which could be included either in the Meeting or in the teaching courses.
Methods: Each author will focus on a specific topic.
A medline will be performed for each topic and summarized in a 10-15 minutes presentation and speakers will present new works on their topic
Results: In order proposed speakers will have a presentation on the following topics: New insight in Menière’s Disease (Julia Dlugaiczyk).
New insight in the pathophysiology of Vestibular Migraine (Michael vonBrevern).
Menière’s Disease and Vestibular Migraine overlappings (Roberto Teggi).
Any instrumental hallmark to distinguish Vestibular Migraine from Menière’s Disease? (Augusto Casani)
Conclusions: The differential diagnosis between the 2 disorders is still under debate, as well as pathophysiology of Vestibular Migraine.
It is also possible that subjects with a menieric phenotype may suffer from attacks of vestibular migraine; this possibility should be clinically investigated and treated when doubted.
Speakers particularly will focus on proposed pathophysiology of VM and possible instrumental tools to differentiate the 2 disorders.
New Insights into Ménière’s Disease- Clinical and Radiological Perspectives
Kuei-You Lin1, Steven D. Rauch2
1Shin Kong Wu Ho-Su Memorial Hospital, Department of Otolaryngology, Taiwan
2Massachusetts Eye and Ear, Department of Otolaryngology-Head and Neck Surgery, United States
Purpose: This study aimed to investigate the potential roles of migraine in Ménière’s disease via both clinical and radiological perspectives.
Methods: According to the disease laterality with the additional consideration of concurrent migraine headache, 1128 patients with Ménière’s disease were divided and received demographical comparisons. Subsequently, 223 of the included patients underwent radiological evaluations. The distributions of different vestibular aqueduct morphology among pathologic ears from various patient groups were analyzed.
Results: In patients with Ménière’s disease, the migrainous group demonstrated a female-to-male ratio of 1.76:1. The female preponderance was especially obvious in unilateral migrainous Ménière’s disease. On the other hand, the patients with unilateral non-migrainous Ménière’s disease was significantly older (50 ± 14 years) than all the other included groups. In terms of the radiological comparison, the bilateral non-migrainous Ménière’s disease group demostrated significantly less degenerative (53%) and more hypoplastic (39%) vestibular aqueducts. Additionally, migraine headache was more noticed in the Ménière’s ears with vestibular aqueducts of the degenerative (22%) than hypoplastic (9%) features.
Conclusions: As a neurologic disease, migraine could affect Ménière’s disease via disturbing the inner-ear blood flow locoregionally and distorting the audiovestibular symptoms centrally. Furthermore, Ménière’s disease might be managed and investigated more appropriately and specifically by utilizing the angular trajectory of vestibular aqueduct, as well as the migraine.
PHEX Gene: A molecular-level window into the etiology of Meniere’s disease
David Bachinger1, Kimberly Ramirez2, Eva S. Liu3, Divya A. Chari4, Andreas H. Eckhard4
1University of Zurich, Zurich, Switzerland
2Department of Otolaryngology - Head and Neck Surgery, University of Massachusetts Chan Medical School, Worcester, MA
3Department of Medicine, Brigham and Women's Hospital, Harvard University, Boston, MA
4Department of Otolaryngology - Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA
Purpose: Recent studies have elucidated the complex and distinct etiologies of Meniere’s disease (MD) by grouping patients with identical or highly similar clinical, radiological, and pathologic characteristics. One MD subgroup demonstrates a radiologic endotype of an underdeveloped (hypoplastic) endolymphatic sac and vestibular aqueduct and a clinical phenotype of male predominance, bilateral disease, and a strong family history of MD. Here, we investigate a potential link between this “MD endo-phenotype,” termed MDhp, and X-linked hypophosphatemia (XLH), a rare phosphate metabolism disorder caused by mutations in the PHEX gene.
Methods: We prospectively recruited XLH patients from two tertiary neurotological centers. Clinical assessment included a medical history of otologic symptoms, pure tone audiometry and speech discrimination, video head impulse testing, and caloric testing. MD endotype was evaluated using high resolution temporal bone computed tomography (CT) imaging. PHEX mutant variants were assessed using whole genome sequencing.
Results: Among the 34 XLH patients recruited (9 male, average age 46.0+16.3 years), 7 male patients exhibited bilateral MD of the “hypoplastic endotype,” while no female patients demonstrated MD. One of the two male patients without MD carried a somatic mosaicism of the Phex mutation. The MD endotype in male patients showed no association with specific Phex mutations.
Conclusions: Our findings suggest a strong epidemiological link between MDhp and XLH. Further, a male-specific distribution of MD among XLH patients was observed, suggesting a PHEX “gene dosage effect” as the cause of MD. These findings link a specific gene to a subgroup of MD patients, paving the way for novel genetic diagnostics and therapeutics.
Predictive Nomograms and an Algorithm for Managing Patients with Probable Meniere's Disease
Mauricio Cohen Vaizer1, Eran Fridman2, Ayelet Eran3, Aram Keywan1, Yona Vaisbuch1, Reuven Ishai1, Roee Noy1
1Rambam Healthcare Campus, Otolaryngology Department, Israel
2Meuhedet
3Rambam Healthcare Campus, Radiology Department, Israel
Purpose: To explore the efficacy of diagnostic tests in accurately reclassifying patients initially diagnosed with Probable Meniere's disease (MD) into either Definite or Non-MD categories.
Methods: A retrospective cohort study was conducted at a neurotology clinic between 1/2016 and 5/2022. Patients underwent a battery of tests, from which sensitivity, specificity, positive and negative predictive values, as well as positive and negative likelihood ratios, were calculated. Additionally, prediction nomograms were developed
Results: Of the 72 patients (85 ears), 35 (41.1%) were initially classified as Definite MD, 27 (31.8%) Probable MD, and 23 (27.1%) non-MD. The mean follow-up was 3.5 years. The sensitivity of Electrocochleography (ECochG) was the highest (92%), with a negative likelihood ratio of 15%. Magnetic Resonance Imaging (MRI) with MD-protocol had the highest specificity (100%), with a positive likelihood ratio of 100%. Videonystagmography, Video Head Impulse Test, and cervical Vestibular-Evoked Myogenic Potentials, had lower sensitivity and specificity. We were able to reclassify 23 (85%) patients with Probable MD: 15 (65%) were diagnosed with Definite MD, and 8 (35%) were diagnosed with non-MD, consistent with their clinical course.
Conclusions: The combination of ECochG and MRI with MD-protocol provides the most reliable approach to reclassify patients with Probable MD, ensuring a precise and accurate diagnosis. Vestibular tests express the functional status of the labyrinth and may not be reliable. Our findings provide valuable insights into clinical decision-making for patients with Probable MD and raise the consideration of additional diagnostic tests as supplementary to the existing clinical-only diagnosis criteria.
Semicircular canal and vestibular plugging in patients with Meniere’s disease: A pilot case series
Daogong Zhang1, Yafeng Lv1, Zhaomin Fan1, Haibo Wang1
1Department of Otolaryngology-Head and Neck Surgery, Shandong Provincial ENT Hospital, Shandong University, Jinan, Shandong, China
Purpose: Currently, therapeutic options are limited for patients with intractable Meniere’s disease who present with recurrent episodes of vertigo and falls. This study aimed to investigate the effectiveness and safety of semicircular canal plugging and vestibular plugging in the treatment of Meniere’s disease with otolithic crises.
Methods: This was a single-center case series with a 7-to-18-month post-operative follow-up. It included patients with intractable Meniere’s disease who presented with recurrent vertigo and drop attacks. All patients underwent surgery for semicircular canal plugging and vestibular plugging. The main outcome measures were vertigo control, drop attack control, hearing, and vestibular function; they were evaluated pre- and post-operatively.
Results: Five patients (three males and two females; mean age, 47.6 years; range, 38–61) underwent the procedure. None had a recurrence of drop attacks; four had no recurrence of vertigo, and one patient had one episode. Two patients had residual hearing before surgery, which was preserved postoperatively. All patients showed altered results in the cervical and ocular vestibular evoked myogenic potential tests, video head impulse test, and caloric test.
Conclusions: Semicircular canal plugging and vestibular plugging appear to be an effective treatment for intractable Meniere’s disease presenting with recurrent vertigo and drop attacks and a promising new surgical modality for these patients. Larger studies are needed to confirm these results.
The Predictive Model for the Differentiation between Vestibular Migraine and Meniere's Disease
Sulin Zhang1, Jun Wang1, Dan Liu1, E t1, Zhaoqi Guo1
1Department of Otorhinolaryngology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan City, Hubei Province, P. R. China
Purpose: Vestibular migraine (VM) and Meniere's disease (MD) share multiple features in terms of clinical presentations and auditory-vestibular dysfunctions, e.g., vertigo, hearing loss, and headache. Therefore, differentiation between VM and MD is of great significance.
Methods: We retrospectively analyzed the medical records of 110 patients with VM and 110 patients with MD. We at first established a regression equation by using logistic regression analysis. Furthermore, sensitivity, specificity, accuracy, positive predicted value (PV), and negative PV of screened parameters were assessed and intuitively displayed by receiver operating characteristic curve (ROC curve). Then, two visualization tools, i.e., nomograph and applet, were established for convenience of clinicians. Furthermore, other patients with VM or MD were recruited to validate the power of the equation by ROC curve and the Gruppo Italiano per la Valutazione degli Interventi in Terapia Intensiva (GiViTI) calibration belt.
Results: The clinical manifestations and auditory-vestibular functions could help differentiate VM from MD, including attack frequency (X5), phonophobia (X13), electrocochleogram (ECochG) (X18), head-shaking test (HST) (X23), ocular vestibular evoked myogenic potential (o-VEMP) (X27), and horizontal gain of vestibular autorotation test (VAT) (X30). On the basis of statistically significant parameters screened by Chi-square test and multivariable double logistic regression analysis, we established a regression equation: P = 1/[1 + e-(-2.269× X5 - 2.395× X13 + 2.141× X18 + 3.949 × X23 + 2.798× X27 - 4.275× X30(1) - 5.811× X30(2) + 0.873)] (P, predictive value; e, natural logarithm). Nomographs and applets were used to visualize our result. After validation, the prediction model showed good discriminative power and calibrating power.
Conclusions: Our study suggested that a diagnostic algorithm based on available clinical features and an auditory-vestibular function regression equation is clinically effective and feasible as a differentiating tool and could improve the differential diagnosis between VM and MD.
The role of MRI in differentiating vestibular migraine from Meniere’s disease
Morgana Sluydts1, Anja Bernaerts2, Bert De Foer2, Catherine Blaivie1, Andrzej Zarowski1, Floris Wuyts3
1European Institute for ORL-HNS, Antwerp, Belgium
2GZA Hospitals Antwerp, Department of Radiology, Belgium
3LEIA, University of Antwerp, Physics Department, Belgium
Purpose: Improving diagnostic accuracy between vestibular migraine (VM) and Meniere's disease (MD) by applying the Bernaerts’ classification (four stage vestibular hydrops grading and asymmetric perilymphatic enhancement grading) on magnetic resonance imaging (MRI).
Methods: A four-hours delayed intravenous contrast-enhanced three-dimensional fluid attenuated inversion recovery (3D FLAIR) MRI was performed on 17 patients diagnosed with MD and 14 patients diagnosed with VM. Both diagnoses were based on the diagnostic criteria as proposed by the International Classification Committee of the Bárány Society. A stepwise logistic regression analysis was performed to identify the essential radiological predicting factors, leading to the most optimal sensitivity for the correct identification of MD versus VM.
Results: The logistic regression showed that the diagnosis MD could be made with a sensitivity of 94,1% and the diagnosis of VM with a sensitivity of 100% when cochlear and vestibular endolymphatic hydrops were considered.
Conclusions: By applying the four-stage vestibular endolymphatic hydrops grading, as proposed by Bernaerts et al., the identification of MD and VM can be made correctly in 94 and 100% of the cases.
Vestibular migraine or Meniere's disease: a diagnostic dilemma
Sulin Zhang1, Jingyu Chen1, Jun Wang1, E Tian1, Zhaoqi Guo1
1Department of Otorhinolaryngology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan City, Hubei Province, P. R. China
Purpose: This review explored the optimal methods of differential diagnosis between MD and VM on the basis of existing studies, trying to find approaches to diagnose the two conditions with higher accuracy. As with any other diseases, differentiating MD and VM based on an objective diagnostic battery rather than solely on the subjective symptoms of the patients can help researchers and clinicians gain insight into the disorders and administer more appropriate treatment.
Methods: This review focused on the differentiation of VM and MD, with an attempt to synthesize existing data on the relevant battery of differentiation diagnosis (covering core symptoms, auxiliary tests [audiometry, vestibular tests, endolymphatic hydrops tests]) and longitudinal follow-up.
Results: Meniere’s disease (MD) represents one of the vertigo disorders characterized by triad symptoms (recurrent vertigo, fluctuating hearing loss, tinnitus or ear fullness). The diagnosis of MD relies on the accurate and detailed taking of medical history, and the differentiation between MD and vestibular migraine (VM) is of critical importance from the perspective of the treatment efficacy. VM is a highly prevalent vertigo condition and its typical symptoms (headache, vestibular symptoms, cochlear symptoms) mimic those of MD. Furthermore, the misdiagnosis in MD and VM could lead to VM patients mistakenly receiving the traumatic treatment protocol designed for MD, and sustaining unnecessary damage to the inner ear. Fortunately, thanks to the advances in examination technologies, the barriers to their differentiation are being gradually removed. These advances enhance the diagnostic accuracy of vertigo diseases, especially VM and MD.
Conclusions: Since the two illnesses are overlapped in all aspects, no single test is sufficiently specific on its own, however, patterns containing all or at least some features boost specificity.
Vestibular Neurotomy for Intractable vertigo in Menieres disease through Minimally Invasive Retrosigmoid Approach
Pradeep Vundavalli1, Jacques Magnan2
1Asian ENT Hospital, Visakhapatnam, India
2University of Aix- Marsielle, France
Purpose: Intractable vertigo in menieres disease is very much debilitating for the patient. The treatment of menieres disease is continously evolving. Most of the cases respond with medication either oral or Intratympanic. All of these treatment options can treat the disease but will not cure the disease. Vestibular Neurotomy for menieres disease with intractable vertigo offers the much needed time for cerebral or central compensation.
Methods: In our series of 42 cases over 7 years, vestibular neurotomy was done through Retrosigmoid approach. All the cases were reported after atleast of 12 months followup.
Results: All the patients who underwent Vestibular Neurotomy for Intractable vertigo with Menieres disease through retrosigmoid approach had got complete remission of symptoms except one patient who developed the symptoms after 18 months which was assumed to be due to opposite side involvement.
Conclusions: We can offer Vestibular neurotomy through Minimally invasive retrosigmoid approach for the patients with menieres disease with intractable vertigo. Vestibular neurotomy can provide complete subsidence of vertigo and also prevents the onset of disease on the opposite side. Accessing the vestibular nerve through retrosigmoid approach for nerve section produces decreased rates of hearing loss and facial palsy when compared to other approaches.
18. Spatial Orientation
A new paradigm for the study of visuospatial memory of vestibular patients in a locomotor navigation task
Bernard S Cohen1, Mohamed Zaoui2, Danielle Cohen1, Idalina Frade1, Alexander Castilla3, Alain Berthoz2
1IRTEV Research Institute of Disorders of Balance and dizziness, Paris, France
2Collège de France, Paris
3Laboratoire de Psychologie et de Neurosciences, Institut de Médecine Environnementale (IME), Paris
Purpose: Vestibular projections to the hippocampus and brain areas involved in spatial orientation and spatial memory during navigation, require new tests with an adequate quantitative evaluation of kinematic and behavioral parameters.
Methods: We used the “virtual carpet”(TM) paradigm (A.Berthoz, M. Zaoui). The subject wears 3D movement and head sensors. 9/10 cm squares are drawn on the ground. (L. Piccardi and C. Guariglia Walking Corsi paradigm). They are illuminated in sequence by a projector.The subject, after observing and memorizing the sequence of tiles, must walk to these tiles in the same order. Three protocols have been used with respectively 1,2,3,4 tiles either eye open of eye closed. Measurements included: walking trajectory, velocity, errors of position and direction, head movements during either locomotion or stops, navigation strategy (sequential egocentric or global allocentric).
Results: 121 male and female subjects were tested (controls; patients with unilateral or bilateral lesion, acute or chronic or without lesion). We will report the results of a subgroup, 44 young women (age <60), with a course comprising 4 tiles. Subjective controls walked and turned faster (66.39+/-26.13 cm/s; 126.87+/-45.18°/s) than any pathological group. Acute UVL walks and rotates the slowest (55.98+/-19.07 cm/s, 96.48+/-34.28°/s). The values of the other pathological groups were close, between these two extremes. It is interesting to note that the maximum head rotation velocity was greater towards the right side for the left AcUVL(143,97°/s vs 99,9°/s) and inversely for the right AcUVL .(106,79°/s vs 113,22 to the left). We describe 4 types of behavior upon arrival on a tile, anticipation/sequential, trajectory error, shortcut and concern to keep the same allocentric reference. Only the control group does not make tiling and shortcut errors.
Conclusions: We will report significant behavioural and quantitative differences between different vertigo patients, which validate the use of this paradigm for testing, and may be for vestibular rehabilitation.
A cross-sectional study on the neurocognitive outcomes in vestibular-impaired school-aged children
Ruth Van Hecke1, Maya Danneels1, Frederik J.A. Deconinck2, Ingeborg Dhooge3, Laura Leyssens1, Emmely Van Acker1, Hilde Van Waelvelde1, Jan R. Wiersema4, Leen Maes5
1Ghent University, Department of Rehabilitation Sciences, Belgium
2Ghent University, Department of Movement and Sports Sciences, Belgium
3Ghent University (Hospital), Department of Otorhinolaryngology/Department of Head and Skin, Belgium
4Ghent University, Department of Experimental Clinical and Health Psychology, Belgium
5Ghent University (Hospital), Department of Rehabilitation Sciences/Department of Otorhinolaryngology, Belgium
Purpose: This study aimed to assess if children with a vestibular impairment (VI) are more prone to have neurocognitive deficits compared to typically developing (TD) peers, taking into account important confounding factors with hearing loss being the most important.
Methods: The neurocognitive performance of fifteen VI children (6-13 years old) was compared to that of an age-, handedness- and sex-weighted group of TD peers (n = 60). Secondly, their performance was also compared to matched groups of TD and hearing-impaired (HI) children to evaluate the involvement of HI. The protocol comprises cognitive tests assessing response inhibition, emotion recognition, visuospatial memory, selective and sustained attention, visual memory and visual-motor integration.
Results: Based on the results, the VI group had significantly reduced scores on ‘social cognition’ (p=0.018), ‘executive functions’ (p<0.01), and ‘perceptual-motor functioning’ (p=0.020) compared to their TD and HI peers. For the categories ‘complex attention’ and ‘learning and memory’ no differences could be observed.
Conclusions: Analogous to the findings of previous literature, the symptoms of a VI are often not limited to the primary functions of the system, but also comprise an impact on emotional and cognitive performance. Therefore, more holistic rehabilitation approaches should be encouraged, with a screening and attention for cognitive, emotional and behavioral dysfunctions in the vestibular population. Since this is one of the first studies to investigate the involvement of a VI in a child’s cognitive development, these findings support the need for studies further characterizing the impact of a VI, the underlying pathophysiology and the effect of different rehabilitation procedures.
Human perception of curved visual and inertial trajectories
Benjamin Crane1, Eric Anson1
1University of Rochester Medical Center
Purpose: Heading direction is perceived from visual and vestibular cues. Vision provides position in space and vestibular provides acceleration. This raises the possibility that these cues are not ideally interpreted but rather vestibular perception is biased towards the heading during peak acceleration. This hypothesis was investigated using a novel technique of ±15° curved trajectories which allowed the portion of the trajectory used to determine heading to be determined.
Methods: Thirty-two healthy human adults (25 female, mean age 25 ±7 years) experienced 15 cm of forward translation on a Moog motion platform over 2s. Headings of up to ±50° were delivered which subjects judged as left or right relative to straight ahead in a 2 alternative forced choice task. Trajectories that were straight and curved ±15° were included. The acceleration occurred either at initial 25%, 50%, or 75% of the movement trajectory. Subsequent stimuli were adjusted based on previous responses to find the point of subjective equality.
Results: Vestibular heading perception was significantly biased based on the initial direction of the curved trajectory. When the acceleration occurred during the first half of the trajectory (deceleration in the second half), the mean bias relative to a straight trajectory was 5.5 ± 0.9° (mean±SD). When the trajectory was modified so that acceleration occurred in the initial 25% the bias was larger at 9.0 ± 0.7° and decreasing the acceleration so that it occurred over the initial 75% of the stimulus decreased the bias to 4.3 ± 1.0°. No such biases were observed when subjects experienced a similar trajectory with only visual optic flow, regardless of the acceleration timing.
Conclusions: This demonstrates human inertial heading perception is based on the direction near the time of peak of acceleration and not integration of the entire trajectory as occurs with visual headings.
Investigating differences in the early visual response to a moving visual field in patients with visual dependency
Vergil V Mavrodiev1, Christopher J Bockisch1, Konrad P Weber2, Fabienne C Fierz3
1Department of Neurology, University Hospital Zurich, Switzerland
2Department of Neurology and Department of Ophthalmology, University Hospital Zurich, Switzerland
3Department of Ophthalmology, University Hospital Zurich, Switzerland
Purpose: Our goal was to study the discrepancies in the early visual response between patients with visual dependency and healthy controls. We utilized the ocular following responses (OFRs) to moving visual fields as well as the participants' ability to suppress eye movements when instructed. OFRs are quick eye movements that track sudden movements of a textured pattern.
Methods: The prospective data was collected from 25 healthy subjects and 9 participants with or without vestibular disorders reporting visual dependency. The subjects were seated in front of a projection screen. A field of dots was projected on the screen, including a moving central visual field with four different radii of visual angle or a moving annular visual field with a stationary center. Two sets of instructions were given: the first one allowed the subjects to follow the moving portion of the dots, and the second one instructed them to fixate a flashing cross in the center without allowing their eyes to move with the dots. Using a video eye tracker, the eye velocity was recorded.
Results: In the healthy group, eye velocities were as follows for the biggest and the smallest radius of a moving visual field - 1.54 ± 0.71°/s (5°) and 2.78 ± 1.42°/s (60°). In the group of subjects with visual dependency, the mean velocities for the same sizes of moving visual fields were as follows: 2.21 ± 1.15°/s and 3.66 ± 1.66°/s.
Conclusions: Subjects with visual dependency exhibited an enhanced ocular following response velocity and an enhanced response to smaller-sized stimuli compared to healthy controls. When given fixation instructions, they showed a decreased ability to suppress the OFR. The findings may contribute to a better clinical characterization of patients with visual dependency, thus forming the basis for targeted treatment approaches.
Mitigation strategies for sustained microgravity exposure in Extravehicular Activities and Lunar Surface Operations
Charles Hughes1, Jon Clark2, Angus Rupert3, Richard Scheuring4
1University of Texas Medical Branch
2Baylor College Of Medicine
3US Army Aeromedical Research Laboratory
4NASA-Johnson Space Center
Purpose: Decrements in human performance due to neuro-vestibular perturbation following exposure to microgravity is well documented. Artemis mission profiles call for extended transit and surface operations compared to the Apollo experience. This effort seeks to enhance performance and operational success using lessons learned to predict and plan mitigation strategies for difficulties experienced in past EVAs and LSOs.
Methods: A literature review on neuro-vestibular system impact due to spaceflight was conducted. Additionally, a review of Apollo resources pertaining to Medical Operations including Apollo medical mission debriefs, Apollo flight surgeon logs, Apollo biomedical engineer (BME) logs, Apollo mission commentaries, Apollo mission reports, Apollo lunar surface journals, preliminary science reports, Apollo lecture series, and personal communications was performed.
Results: The NASA neurologic function rating scale indicates most common/significant decrements occur in gait, station, and gaze control. These decrements were studied in Space Transportation System missions (comparable mission duration to the longer Artemis transits). Lessons learned from Apollo LSOs included: (1) Falls on moon occurred regularly - 6 Apollo lunar surface missions with 12 astronauts during 14 EVAs there were 23 falls and 11 stumbles. (2) Astronauts ambulated with modified gait (skips on flat terrain, kangaroo hops on hills). (3) “wobbly sensation” reported on lunar surface with coordination improving over 2 hours on the surface. (4) Apollo astronauts sustained injury from surface operations, suit fit and mobility constraints. (5) Sustained workload often exceeded an astronaut’s physical capability.
Conclusions: The potential risk of injury to crewmembers is inherent in aggressive surface activities, whether they be Moon, Mars, or asteroid-based. Identifying potential issues and mitigation strategies for difficulties experienced in past EVAs and LSOs can test, prepare, and increase chances for success in future endeavors. Discussion includes testing modalities, multisensory cueing technology programs, and relevant countermeasures to reduce spatial disorientation and enhance habituation that could reduce mishaps.
Patients with peripheral vestibular dysfunction and mental rotation in fMRI
Corina G. Schöne1, Gerda Wyssen2, Gianluca Macauda2, Dominique Vibert3, Fred W. Mast2
1Department of Psychology, University of Bern, Bern, Switzerland; Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
2Department of Psychology, University of Bern, Bern, Switzerland
3Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
Purpose: Peripheral vestibular dysfunction (PVD) impairs spatial cognition. However, the mechanisms through which PVD impacts spatial cognition are still elusive.
Methods: We used functional magnetic resonance imaging (fMRI) during a mental self-rotation task to compare brain activation between patients with PVD and healthy controls matched for age, sex, education, and handedness. We included patients with various conditions of PVD: unilateral acute (n = 12), unilateral chronic (n = 18), and bilateral (n = 17).
Results: All patient groups performed slower in the mental rotation task compared to healthy controls, with the strongest impairment observed in patients with acute unilateral PVD. Whole brain comparisons of mental rotation networks between patients and controls did not differ. Regarding the regions of interest, brain activation did not differ between patients and controls in the superior parietal lobe, inferior parietal lobe, Rolandic operculum, and right hippocampus. In the left supramarginal gyrus, patients with unilateral acute PVD showed a different activation pattern compared to controls.
Conclusions: In this first study investigating neural correlates of mental self-rotation in patients with PVD, we found impaired mental self-rotation performance but preserved mental rotation networks in patients with PVD. Impaired mental rotation performance in patients might result from a failed integration of actual body position signals and mental self-rotation processes, rather than an absent mental rotation network. The preserved mental rotation network in patients with PVD highlights the potential of incorporating mental self-rotation tasks into vestibular rehabilitation programs.
Relation Between Visuospatial Inhibitory Attention and Vestibular Spatial Orientation Perception
Erin Hernon1, Erin G. Piker2, Hannah Martin1, Kristal M. Riska1
1Duke University, Department of Head and Neck Surgery and Communication Sciences, United States
2James Madison University, United States
Purpose: The purpose of this study was to examine the relation between the cognitive domain of visual spatial attention and performance on a vestibular spatial orientation perceptual task in adults.
Methods: 32 adults aged 60 years and older were administered the Flanker Inhibitory Attention and Control Test, a measure of visuospatial inhibitory attention. Participants viewed a series of images, each containing a central target stimulus flanked by similar stimuli. Their task was to designate the direction of the central image while ignoring the irrelevant flanking stimuli. The same cohort also underwent a vestibular psychophysical task to test perception of spatial orientation during yaw-axis rotation. Without visual or auditory cues, participants identified their perceived maximum displacement at various frequencies (.08-.64 Hz) and peak velocities (30-90 deg/sec). Spatial orientation error was calculated as the difference between perceived and true maximum displacement.
Results: The average age-and education-adjusted t-score on the Flanker test was 48.6 (SD = 9.85). Average spatial orientation error across all conditions was 26.19 (SD = 12.52) degrees. An overall weak positive correlation (r = .24) was found between Flanker t-score and spatial orientation error, where better performance on the visuospatial inhibitory attention task was weakly associated with worse performance on the vestibular spatial orientation perception task.
Conclusions: There is not a strong relationship between visuospatial inhibitory attention and vestibular perception of spatial orientation during yaw rotation at .08-.64 Hz. Further research is needed to better understand performance in a larger cohort of individuals and is part of on-going work in our research lab.
Statement of Responsibility: The co-authors agree with the states results and have consented to inclusion as authors. Work involving humans or animals, or material derived from them, was approved by an institutional ethics committee.
Spatial numerical bias in patients with acute vertigo
Sally Rosengren1, Ben Nham2, Jasmine Lim3, Michael Halmagyi1, Miriam Welgampola1
1Royal Prince Alfred Hospital, Institute of Clinical Neurosciences, Australia
2University of Sydney, Central Clinical School, Australia
3Macquarie University, Psychology Department, Australia
Purpose: Number magnitude is often represented spatially in the brain by a mental number line, on which small numbers are located to the left of space and large numbers to the right. As vestibular dysfunction can affect aspects of spatial cognition, we wondered whether patients with acute vestibular loss would show a directional bias along the mental number line.
Methods: We gave 19 patients with vestibular neuritis (VN) (11 left VN, 8 right; mean age 54 yrs, range 31-75 yrs; 5 females) and 15 normal age- and education-matched controls (mean age 47 yrs, range 26-75 yrs; 11 females) a mental number bisection task.
Results: Patients with left VN underestimated the middle number (mean sum of signed errors -3.3, SE 1.5), while patients with right VN overestimated it (mean 1.4, SE 0.8). The direction of effect aligned with the direction of slow phase velocity. Results for the normal controls fell in between the two patient groups, and represented an underestimate of the middle number (mean -1.5, SE 0.8). In the patients, the effect was greater without visual fixation and in the acute stage compared to one or two weeks later. Error rates were similar across all groups and conditions.
Conclusions: Our results show that acute vestibular loss produces a temporary bias in spatial numerical processing that is only present in the absence of visual cues. The effect is similar to that seen in patients with visuospatial neglect.
Velocity storage dynamics in health and disease: optimal estimation based on neural noise
Amsal Madhani1, Ilhan Yunus2, Faisal Karmali1
1Harvard Medical School / Massachusetts Eye and Ear, Boston, USA
2Harvard Medical School / Massachusetts Eye and Ear, Boston, USA / KTH Royal Institute of Technology, Stockholm, Sweden / Volvo Cars, Gothenburg, Sweden
Purpose: The vestibular and visual organs are imperfect, yet the brain is able to synthesize a robust estimate of three-dimensional motion and orientation in most individuals. The mechanisms that perform this estimation process include velocity storage. For example, the velocity storage time constant is an important clinical parameter which varies with age and peripheral damage. Importantly, a mechanistic explanation for the relationship between vestibular damage and changes in these behaviors is lacking. It has been hypothesized that optimal estimation determines velocity storage dynamics based on the statistics of vestibular neural noise (i.e., variability) and experienced motion. Specifically, while a longer time constant would be advantageous because this would make the VOR accurate over a longer period of time, it has been argued that this would result in the accumulation of noise by the velocity storage mechanism, which would result in drift and make the VOR less precise. We have studied the hypothesis that the brain determines the time constant based on vestibular noise to determine the optimal tradeoff between being accurate and being precise.
Methods: The central nervous system is modelled as an optimal estimator that uses information from the vestibular organ to determine spatial orientation. The term 'optimal' refers to designing estimators to minimise mean-square errors, especially with system and measurement noise.
Results: First, we found that these models predict reduced velocity storage time constants for unilateral lesions. Second, we found that age-dependent changes in the VOR are explained by a velocity storage model responding to death of motion-sensing hair cells. To study three-dimensional processing, we are currently expanding existing models using new techniques which are computationally efficient.
Conclusions: Together, these results explain variations in central spatial-orientation processing. This modelling approach not only enhances our theoretical understanding but also can be used to design systems that help individuals with orientation problems.
Vestibular contributions to visual search in patients with Alzheimer’s disease
Koray Koçoğlu1, Hatice Eraslan Boz1, Müge Akkoyun1, Pınar Özçelik1, Işıl Yağmur Tüfekci1, G. Michael Halmágyi2, Gülden Akdal3
1Department of Neurosciences, Institute of Health Sciences, Dokuz Eylül University, Izmir, Turkey
2Neurology Department, Royal Prince Alfred Hospital, Sydney, Australia
3Department of Neurology, Dokuz Eylül University, Izmir, Turkey
Purpose: Cognitive impairment correlates with vestibular impairment (VI). We tested visual search in patients with cognitive impairment with or without VI.
Methods: Twenty-eight patients with Alzheimer’s Disease (AD), 29 with amnestic mild cognitive impairment (aMCI), and 30 healthy controls (HCs) all had a neurological assessment, comprehensive cognitive testing, and a visual search test to find a target. All participants had vestibular function testing with 10 subtests: air- and bone-conducted cervical/ocular vestibular-evoked myogenic potentials and 6 canals video Head Impulse Test (vHIT). Participants were classified into two categories: Normal vestibular function if all 10 subtests were normal (or only one subtest was abnormal); and VI if two or more subtests were abnormal. VI severity was determined by the total number of abnormal subtests.
Results: AD with VI (n =17) showed significantly shorter target fixation durations, fewer correct responses and fixations than AD without VI (n = 11). Although the results of visual search parameters were lower in aMCI and in HCs with VI than in those without VI, differences were not as significant as in AD. There was a significant negative correlation between the severity of VI and visual search parameters: severe VI associated with lower visual search performance. Age, duration of disease, depression, anxiety, and cognitive test scores for different domains were not significantly different in AD with or without VI.
Conclusions: AD patients with VI have difficulty in finding a target in visual search task, even though cognitive scores were not different in AD with or without VI. Therefore, there might be additional effects of VI in patients with severe cognitive impairment, such as those with AD. Our findings suggest that visual search testing could be used to screen for the effects of VI in patients with cognitive impairment.
Selected references
Vestibular Function is a Hidden Harbinger of Human Hypoxia
Dan Merfeld1, Max Teaford2, Anne Crecelius3, Zachary J Mularczyk4, Kyle A Pettijohn4
1Ohio State University, Otolaryngology, USA & Naval Medical Research Unit - Dayton (NAMRU-D)
2University of Tennessee at Chattanooga, Psychology, USA
3University of Dayton, USA
4Naval Medical Research Unit - Dayton (NAMRU-D)
Purpose: The aim of this study was to evaluate the impact of hypoxia on human vestibular function.
Methods: To quantify the impact of reduced O2 on vestibular function, we used standard forced-choice psychophysical methods to quantify earth-vertical translation thresholds - the smallest upward/downward translation that a seated human could reliably sense. To manipulate blood oxygenation, normobaric hypoxia was induced using a Reduced Oxygen Breathing Device. All data were collected at Wright-Patterson Air Force Base (elevation 823’). On different days, participants breathed air having O2 content of 20.9%, 15.4%, 14.3%, 12.9%, 11.8%, and 10.7% – to simulate O2 content found at altitudes of 0’ (“baseline”), 8,000’, 10,000’, 12,500’, 15,000’, and 17,500’.
Results: Fifteen participants completed test sessions at 20.9% and 15.4% O2. Earth-vertical translation thresholds were 23.5% greater when the oxygen content was 15.4% than at 20.9% (p=0.005, Wilcoxson Sign Rank Test, Z = -2.84). A second set of participants was invited to complete test sessions at 20.9%, 14.3%, 12.9%, 11.8%, and 10.7% O2. Earth-vertical translation thresholds increased as O2 content decreased. All healthy subjects reported no spatial disorientation or perceptual illusions. In contrast, a patient diagnosed with unilateral vestibular hypofunction reported disorientation and illusory tilt when mildly hypoxic.
Conclusions: These results show that vestibular thresholds are both significantly and substantively impacted at simulated altitudes as low as 8,000’. These results suggest that commercial jet passengers may experience degraded vestibular function due to mild hypoxia. Behavioral impacts remain to be understood, but vestibular function appears to be a hidden harbinger of hypoxia.
23. Vestibular Compensation and Rehabilitation
Digital Advancements in Vestibular Rehabilitation:Evaluating the Effectiveness of Online Therapy
Anita Bhandari1, Rajneesh Bhandari1, Anushka Bhandari1
1NeuroEquilibrium
Purpose: Vestibular rehabilitation is an important modality of treatment of several vestibular disorders. The rehabilitation protocol needs to be customised according to the vestibular deficit. This study evaluates the efficacy of online Vestibular rehabilitation program for dizzy patients.
Methods: 93 patients were enrolled in the online rehabilitation program. The Dizziness Handicap Inventory (DHI) score was employed as the primary metric for measuring progress. Change in symptoms were also recorded.
Results: After completion of 6 online rehabilitation sessions, the average DHI score reduced from 38.1 to 16.5. Quantitatively, a 58% decrease in vertigo symptoms was observed post-rehabilitation. Detailed post-rehabilitation outcomes indicated 81.7% participants experienced improvement in vertigo, 5.4% achieved complete resolution and 12.9% reported no change.
Conclusions: The study emphasizes the role of digital healthcare in delivering effective vestibular rehabilitation. The accessibility and tailored treatment plans of the digital platform stand out as key advantages. Further research is suggested to validate these findings on a larger scale.
Acceptability of Vestibular Physical Therapy Modifications for Individuals with Cognitive Impairment
Brooke Klatt1, Yuri Agrawal2
1University of Pittsburgh, Department of Physical Therapy, USA
2University of Colorado School of Medicine, Department of Otolaryngology - Head & Neck Surgery, USA
Purpose: People with Alzheimer Disease (AD) have an increased prevalence of falls and vestibular hypofunction, yet they are not typically referred for vestibular physical therapy (VPT). Modifications to VPT that use motor learning principles to leverage the learning abilities of the individual have been proposed for application to individuals with cognitive impairment, but the acceptability and usability has not been studied.
Methods: Six participants (3 males and 3 females, mean age = 79) with mild-AD completed an 8-week course of VPT with application of modifications to VPT were tracked and acceptability was determined with an end of study survey. Preliminary efficacy was assessed by analyzing change in gait speed, five-time sit-to stand (FTSTS), timed up and go (TUG), and Mini-BESTest.
Results: Specificity of training, perceptual priming strategies, salient functional balance tasks, and use of meaningful gaze stabilization targets were used were used for all participants each training session. All six participants were able to follow 100% simple commands for balance tasks. Modifications for gaze stabilization were required for four of the six participants whereby verbal cuing to maintain gaze fixation and/or head movement was used. Two of the participants additionally required a modification to aid head movements with tactile assistance. 100% of the participants completed the study. On a 1-5 scale (1=strongly disagree to 5=strongly agree), 6/6 participants reported “5” for enjoyment in the training and 5/6 strongly agreed that the training helped their balance and function (1/6 reported “4”/“agree” that the training was helped improve their balance). Each of the participants demonstrated an improvement in at least one of the performance outcomes.
Conclusions: Our findings indicate that our modified VPT protocol was acceptable and well tolerated in our sample. Additionally, the pilot data suggests that VPT might benefit people with mild-AD and larger studies are warranted.
Barriers and facilitators of vestibular rehabilitation: Patients and physiotherapists’ perspectives
Liran Kalderon1, Azriel Kaplan1, Amit Wolfovitz2, Shelly Levy-Tzedek3, Yoav Gimmon4
1Ben-Gurion University of the Negev, Department of Physical Therapy, Israel
2Sheba Medical Center, Department of Otolaryngology- Head and Neck Surgery, Israel
3Ben-Gurion University of the Negev, Department of Physical Therapy, Israel; Ben-Gurion University of the Negev, Zelman Center for Neuroscience, Israel; University of Freiburg, Freiburg Institute for Advanced Studies (FRIAS), Germany
4Sheba Medical Center, Department of Otolaryngology- Head and Neck Surgery, Israel; University of Haifa, Department of Physical Therapy, Israel
Purpose: Poor adherence to vestibular rehabilitation protocols is a known barrier to optimal care. Vestibular clinicians' comprehensive understanding of the barriers and facilitators to vestibular home-exercise programs (VHEP) is a key element to achieving optimal care in the context of vestibular rehabilitation. The aims of this study are: (1) to identify primary barriers and facilitators to VHEP from the perspective of patients with vestibular dysfunction (VD) and vestibular physical therapists (PTs); (2) to provide strategies for clinicians to improve adherence and outcomes of VHEP
Methods: A qualitative research with single-session focus groups conducted separately for: (1) patients with vestibular disorders; (2) vestibular PTs. Six focus groups were conducted, three for each population, with a total of 39 participants. An online survey was conducted to evaluate the estimates of adherence rates, followed by a structured discussion over barriers and facilitators to VHEP as perceived by patients and PTs. Thematic data analyses were performed, using a mixed deductive-inductive approach.
Results: Eighteen patients with vestibular disorders and 21 experienced vestibular PTs participated in this study. Six barrier categories and five facilitator categories were identified. Barriers included: motivation aspects; provocation of symptoms; time management; associated impairments; missing guidance and feedback; psychosocial factors. Facilitators included: motivation aspects; time management; patient education and exercise instructions; exercise setting; associated symptom management.
Conclusions: Clinicians who prescribe home exercise to patients with vestibular disorders can use this information about common barriers and facilitators for patient education and to provide optimal care and improve rehabilitation outcomes.
Effectiveness of Virtual Reality in People with PPPD: A Randomized Controlled Trial
Alia Alghwiri1, Madlien Al-Omari2, Sawsan Abuzaid2, Hamzeh Khair2, Haidzir Manaf3
1The University of Jordan, Jordan
2Royal Medical Services, Jordan
3Universiti Teknologi MARA, Malaysia
Purpose: To assess the comparative effectiveness of virtual reality (VR) versus vestibular rehabilitation therapy (VRT) in enhancing PPPD symptoms (balance and dizziness) and other dimensions of PPPD including mental well-being, sleep quality, fall risk, and overall quality of life.
Methods: A cohort of 42 individuals with PPPD were randomly assigned into two groups. The experimental group included 21 participants who received a combination of VR and optokinetic stimulation in addition to VRT, while the control group, also made up of 21 individuals, only received optokinetic stimulation and VRT. We administered the intervention sessions twice weekly over a span of 6 weeks, resulting in a total of 10-intervention sessions. Additionally, baseline, post-intervention, and follow up assessments were conducted to measure the short- and long-term effectiveness of the interventions.
Results: Our analysis revealed that participants within the experimental group exhibited significantly enhanced balance outcomes (P<0.01) upon completion of the intervention compared to their counterparts in the control group. Notably, individuals undergoing VR interventions demonstrated marked improvements across all of the assessed parameters. However, participants in the control group also displayed notable enhancements in select outcome measures post-intervention. All participants maintained significant improvement in the severity of PPPD after 1 year of the intervention.
Conclusions: Researchers have found that using VR interventions with optokinetic stimuli alongside VRT as a cohesive therapeutic program seems like a promising method for ameliorating symptoms associated with PPPD. The utilization of VR goggles was found to be both safe and economically viable for the management of individuals afflicted with PPPD.
Factors Associated with Dizziness Handicap in Patients with Vestibular Schwannoma
Nedim Durakovic1, Nicholas Rapoport1, Lauren English1, Belinda Sinks1, Joel Goebel1
1Washington University in St. Louis, Department of Otolaryngology, USA
Purpose: To evaluate severity of patient-reported dizziness in patients with vestibular schwannoma (VS) and correlation with age, sex, comorbidities, anxiety, vestibular testing, and tumor characteristics.
Methods: A retrospective cohort study of patients diagnosed with VS by MRI at a tertiary referral center was performed from 2019 to 2024. Patients who also completed a pre-treatment, self-reported Dizziness Handicap Inventory (DHI) and vestibular testing including video oculography (VOG) were included. Variables also evaluated included ACE-27 comorbidity score, self-reported generalized anxiety disorder 7-item (GAD-7) score, and tumor size. Multivariable linear regression was used to determine factors independently associated with DHI scores and caloric asymmetry.
Results: 60 patients were included, with a median age of 69 (range 27-88) years, and even number of males and females (n=30). Mean DHI score was 27.46 (SD 23.19) and mean caloric deficit was 47% (SD 39.5). After multivariable linear regression, GAD-7 score was positively correlated with DHI score (B = 2.8 95% CI 1.71 – 3.79, p < 0.001; pearson correlation coeff 0.62). Larger tumor size was negatively correlated with DHI score (-12.7% difference between small and large tumors, pearson correlation coeff -0.22, p = 0.018) while other factors including age, sex, and medical comorbidities were not statistically significant. Conversely, larger tumor size was positively correlated with vestibular dysfunction on caloric testing, (36% difference between small and large tumors, pearson correlation coeff 0.43, p =0.001) while no other factors were significant.
Conclusions: Several factors account for heterogeneity of dizziness handicap in patients with vestibular schwannoma. Larger tumor size is associated with greater caloric asymmetry (poorer ipsilateral vestibular function), but also with improved DHI scores while more severe anxiety is correlated with worse patient reported DHI scores.
Galvanic vestibular stimulation to rehabilitate postural instability in Parkinson’s disease
Anna Paula Batista de Ávila Pires1, Ludimila Labanca2, Paulo Pereira Christo3, Maurício Campelo Tavares4, Jordana Carvalhais Barroso1, Maria Luiza Diniz1, Denise Utsch Gonçalves5
1Postgraduate Program in Speech-Language-Hearing Sciences, Federal University of Minas Gerais, Belo Horizonte, Brazil
2Medical School, Department of Speech-Language-Hearing Sciences, Federal University of Minas Gerais, Belo Horizonte, Brazil
3Medical School, Department of Medical Clinic, Federal University of Minas Gerais, Belo Horizonte, Brazil
4Electrical Engineer, PhD
5Medical School, Department of Otorhinolaryngology, Federal University of Minas Gerais, Belo Horizonte, Brazil
Purpose: Galvanic Vestibular Stimulation (GVS) is a non-invasive method that has been used to rehabilitate body balance through short-term electrical stimulation and low current in the mastoid bones that stimulates the vestibulespinal tract. The objective was to evaluate the balance response to GVS in patients with Parkins’s disease (PD) and postural instability.
Methods: In a clinical study, 25 patients with PD and postural instability in the ON phase were submitted to GVS and were evaluated using the Berg Balance Scale (BBS), Time Up and Go test (TUG), and posturography testing on a force platform. The intensity of the electrical current between the mastoids was increased gradually from 1.0 milliamps (mA) to 3.5 mA until the 6th session and held until the 8th session. Stimulation time was progressively increased from 9 minutes in the 1st session to 30 minutes in the 3rd session and kept until the 8th session.
Results: In a blindly comparison of the evaluations before and after GVS, the results showed improvement in BBS (p= 0.00001) and in TUG (p=0.00003) scores. In the posturography, an increase in the stability limit area (p=0.026) and in the general balance index (p=0.001) was observed.
Conclusions: In the current therapeutic context of managing postural instability associated with PD, GVS was shown to be an attractive complementary strategy to improve balance, considering its safety, possibility of home use and easy learning to handle the technique. It remains to be assessed whether the balance gain is maintained after the interruption of GVS.
Gaze stability asymmetry: a measure of physiologic recovery in pediatric mild traumatic brain injury
Amy Alexander1, Rachel Sweenie2, Bradley Mecham3, Jamie Pardini4
1Banner Sports Medicine and Concussion Specialists, Banner–University Medical Center, USA; Lentsch Family Concussion Center, Banner Sports Medicine Scottsdale, USA
2Banner Sports Medicine and Concussion Specialists, Banner–University Medical Center; Lentsch Family Concussion Center, Banner Sports Medicine Scottsdale; University of Arizona College of Medicine, USA
3Banner Sports Medicine and Concussion Specialists, Banner – University Medical Center Phoenix, USA
4Lentsch Family Concussion Center, Banner Sports Medicine Scottsdale; University of Arizona College of Medicine – Phoenix, Internal Medicine and Neurology Departments, USA
Purpose: Sport-related mild traumatic brain injury (mTBI) can cause a physiologic disruption in the vestibular system resulting in dizziness, imbalance, and blurry vision. The gaze stability test (GST) is a functional measure of the angular vestibular ocular reflex. GST asymmetry has been shown distinguish between athletes with a history of mTBI and those without. Asymmetry has not been examined in youth.
Methods: A retrospective chart review of 117 athletes aged 9 to 17 years (Mean = 14.51, SD ±2.08) to examine GST velocities and asymmetry at the start of vestibular physical therapy (T1) and once a post mTBI baseline was established (T2). Athletes were prescribed exercises based on test results and modified for their sport between T1 and T2. Descriptive statistics and Wilcoxon signed-rank tests were conducted.
Results: T1 median GST in leftward direction head movements (GST-L) was 145°/s (range=85 to 230°/s). For rightward direction head movements (GST-R), median velocity was 114°/s (range=94.5 to 255°/s). Median GST asymmetry for T1 was 9.09% (range=0% to 26.09%).
T2 GST-L median velocity was 210°/s (range=174.5 to 275°/s). T2 median GST-R was 210°/s (range=165.9 to 266°/s). Median asymmetry for T2 was 3.16% (range=0% to 10.13%).
GST-L, GST-R, and asymmetry significantly improved from T1 to T2 (ps > .001).
Conclusions: Using functional assessments, like the GST, and examining asymmetry may advance the clinician’s insight into an athlete’s ability, response to their custom home exercise program, and readiness to advance through late stage of return to play.
Physiotherapy interventions in vertigo and dizziness – a scoping review
Ann-Sofi Kammerlind1, Berit Bjerlemo2, Helena Fridberg3, Susanne Gripenberg4, Carolina Halén5, Lena Hallin6, Lena Kollén7, Helena Löwen-Åberg8, Eva-Maj Malmström9, Ulrika Olsson Möller10, Marie Thurfjell11, Eva Ekvall Hansson12
1Futurum, Region Jönköping County, Jönköping, Sweden & Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
2Municipal rehabilitation center, Communal Primary Care, Region Västra Götaland Skene, Sweden
3Community Medicine and Rehabilitation, Umeå University, Umeå, Sweden
4Allied Health Professionals, Karolinska University Hospital, Stockholm, Sweden & Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden
5Allied Health Professionals, Karolinska University Hospital, Stockholm, Sweden
6Primary Care Rehabilitation, Närhals Tjörn, Region Västra Götaland, Kållekärr, Sweden
7Department of Occupational Therapy and Physiotherapy, Sahlgrenska University Hospital, Gothenburg, Sweden & Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Sweden
8Primary Care Rehabilitation, Region Västra Götaland, Gothenburg, Sweden
9Department of Clinical Sciences, Lund University, Lund, Sweden
10Department of Health Sciences, Kristianstad University, Kristianstad, Sweden & Department of Clinical Sciences, Lund University, Lund, Sweden
11Rehabilitation and Pain Centre, Uppsala University Hospital, Uppsala, Sweden
12Department of Health Sciences, Lund University, Lund, Sweden & Department of Otorhinolaryngology, Head and Neck Surgery, Skane University Hospital, Lund, Sweden
Purpose: The aim of this scoping review was to identify and describe the available evidence in the field of physiotherapy interventions for dizziness and vertigo of different causes and to identify knowledge gaps as well as priorities for future research.
Methods: Six medical databases were searched and 20.880 records identified. After removing duplicates, an extensive process of blinded screening and reviewing of titles, abstracts, and 2.161 full-text articles followed. Eligibility criteria was systematic reviews and original publications with any design, including participants with diagnosis of vertigo or dizziness of any origin, and physiotherapy interventions of any kind. Finally, 1.339 publications were included.
Results: The most common diagnose was benign paroxysmal positional vertigo (n=635) followed by mixed specified diagnosis (n=189), unilateral vestibular loss (n=118), and mild traumatic brain injury (n=83). The most common type of intervention was maneuver treatments (n=602) followed by four categories of vestibular rehabilitation exercises (n=515). Intervention studies without control group was the most common design (n=379), followed by randomized controlled studies (n=304), and case reports and series (n=270). In median, 40 (range 1-3060) participants were included in the original studies (reviews not included). There was a large increase in the number of studies over time from the first published study in 1963 until the search was performed in 2023.
Conclusions: The scientific basis for physiotherapy interventions for dizziness and vertigo varies considerably between diagnoses and intervention types. Knowledge gaps were identified as well as priorities for future research.
Punching Wombats: An Australian Approach to Vestibular Rehabilitation
Miranda Morrison1, Diego Herrero1, Anousha Rafi1, Alyssa Dyball1, Belinda Kwok1, Juno Kim2, Miriam Welgampola1
1Central Clinical School, Faculty of Medicine and Health, The University of Sydney, NSW, Australia
2School of Optometry and Vision Science, University of New South Wales, NSW, Australia
Purpose: To assess the effectiveness of Virtual Reality (VR) in delivering an effective, safe, and more engaging vestibular physiotherapy to patients with unilateral and bilateral vestibular loss.
Methods: We conducted a prospective pilot study on 28 patients with imbalance from unilateral or bilateral vestibular loss presenting to a neurotology outpatient facility (Royal Prince Alfred Hospital, Sydney). Patients filled out questionnaires on dizziness and imbalance symptoms (DHI and ABC scales) and impact on quality of life (EuroQol5), alongside which, a vestibular clinical exam was performed by a neurotologist (video-oculography, Romberg, vHIT and Functional Gait Analysis). Patients then undertook 6 weeks of daily ‘Virtual Reality’ rehabilitation. On follow-up, the DHI/ABC/EuroQol5 questionnaires together with VOG/VHIT/FGA were repeated and scores were examined for potential improvement.
Results: From the 28 patients recruited in the study, 25 completed the 6 weeks of ‘Virtual Reality’ rehabilitation, of which, 75% followed the full protocol. Although no significant improvement was noted on objective clinical measures (i.e., vHIT and FGA), subjective measures all showed significant improvement: DHI (43.9±20.9 before, 27.6±17.6 after p < 0.001), ABC scale (63.3±21.7 before, 70.4±19.7 after, p = 0.038) and EuroQol5 (67.2±22.4 before, 76.2±12.4 after p = 0.036). No patients sustained any injuries during the use of the device and most found the device fun to use.
Conclusions: ‘Virtual Reality’ rehabilitation is feasible, safe to use and engaging with excellent patient compliance and holds promise as a means of optimizing home-based balance rehabilitation. Although objective clinical measures did not improve, there were significant improvements in subjective measures of symptom severity (DHI, ABC and EuroQol5 scales).
Remote and wearable sensor enabled vestibular rehabilitation for Multiple Sclerosis: Usability and outcomes
Dara Meldrum1, Hugh Kearney2, Siobhan Hutchinson2, Sheila McCarthy3, Gillian Quinn4
1School of Medicine, Trinity College Dublin Ireland
2Dept of Neurology, St. James Hospital Dublin Ireland
3St. Mary's Hospital, Dublin, Ireland
4Physiotherapy Dept, St. James Hospital Dublin Ireland
Purpose: Vertigo, dizziness, gaze instability and disequilibrium are highly prevalent in people with MS (PwMS) and head movement induced dizziness is commonly reported. Vestibular physical therapy (VPT) is a specialised, non-invasive and effective therapy and the use of wearable sensors to track head movement and smartphone applications to deliver and track programs has potential to improve VPT in MS.
Methods: This study investigated the usability and effects of a commercially available digital VPT system (wearable head sensor, smartphone app and clinician software) to deliver VPT to pwMS. A pre/post treatment design was employed and the primary outcome was the System Usability Scale (SUS). Other patient reported outcomes were the Service User Acceptability Questionnaire (SUTAQ), the Patient Enablement Instrument (PEI) and the Dizziness Handicap Inventory (DHI). Physical outcomes measurements included MiniBestTest (MB), Modified Dynamic Gait Index (mDGI), Gait Speed (GS), Dynamic Visual Acuity (DVA) and head kinematics and symptoms during exercise.
Results: Sixteen pwMS (14 female), mean age 44(±14) years were recruited and twelve completed VPT. Mean adherence to exercise, measured digitally was 60% (±18.4). SUS scores were high at 81 (±14). Significant improvements in MB (mean change 2.25; p=0.004), mDGI (median change 1.00; p=0.008), DVA (median change -1.00; p=0.004) were found. Head frequencies significantly improved with concurrent decreased intensity of dizziness (mean change across 4 gaze stabilization exercises was 23 beats per minute; p<0.05). Non-significant improvements were seen in DHI (p=0.07) and GS (p=0.15). 64.5% of follow up visits were conducted remotely (video or phone), facilitated by the system.
Conclusions: This study has demonstrated high usability of a wearable head sensor combined with a digital application enabling remote VPT in pwMS. The system was well tolerated and accepted with no adverse events. Reductions in dizziness at increasing head frequencies were observed with concurrent improvements in balance and gait.
Somatosensory and Vestibular Enhancement of Adaptation in Falls - SaVE -A-Fall
Eva Ekvall Hansson1, Per-Anders Fransson2, Ulrik Röijezon2, Måns Magnusson2
1Lund University, Department of Health Sciences, Lund
2Sweden
Purpose: The aim of this study was to investigate the possible improvement of postural stability when healthy younger and older adults were repeatedly exposed to an immersive virtual environment. In high-risk individuals prone to falls, poor balance is a marked predictor for future falls. Individual tailored interventions should be used, as lined out by world guidelines for fall prevention. Older people with persistent balance impairment use vision to a higher degree to maintain balance and they seem to have a resistance to the ordinary approach with balance exercises or vestibular rehabilitation. Virtual Reality (VR) can address the complexity of persistent balance disorder. Before conducting an RCT using VR as an intervention, the adaptation of the balance system to VR should be analyzed.
Methods: Twenty subjects were included in the younger group (mean age 24.5) and twenty-seven in the older group (mean age 71.3). Both groups were exposed to VR stimuli, standing on a force plate, assessing postural sway. The younger group watched a roller coaster ride and the older group a 360° “walking in a grocery store” video, including numerous stops/starts and quick turns. The movies were repeated five times with rests between.
Results: Both groups adapted to the distortive visual environments, shown as reduced postural sway during the consecutive tasks. Thus, CNS can utilize the information provided by a few repeated VR sessions into suitable movement strategies that have a simultaneous multidimensionally positive effect.
Conclusions: Virtual Reality may introduce opportunities to customize or develop novel rehabilitation approaches to address persistent balance impairments, especially among groups who use vision to a high degree to maintain balance.
The comparison between prehabilitation with gentamicin and vestibular training in patients with vestibular schwannoma
Marketa Bonaventurova1, Kvetoslav Cerveny1, Rudolf Cerny2, Veronika Bandurova1, Zdenek Fik1, Martin Komarc3, Zdenek Cada4, Zuzana Balatkova1
1Department of Otorhinolaryngology and Head and Neck Surgery, 1st Faculty of Medicine Charles University in Prague and Motol University Hospital Prague, Czechia
2Department of Neurology, 2nd Faculty of Medicine, Charles University in Prague and Motol University Hospital Prague, Czechia
3Department of Anthropomotorics and Methodology, Faculty of Physical Education and Sport, Charles University in Prague, Czechia
4Department of Otorhinolaryngology and Head and Neck Surgery, 2nd Faculty of Medicine Charles University in Prague and Motol University Hospital Prague, Czechia
Purpose: Resection of the vestibular schwannoma (VS) leads to an acute peripheral vestibular loss. The process of central compensation occurs immediately after. The rehabilitation goal is to support this process and restore the quality of life.
Methods: In this prospective single-center study, 41 consecutive patients underwent VS resection (28 females, mean age 52±13). The patients were divided into two groups. Prehabilitation with intratympanic gentamicin group (ITGG) underwent chemical ablation with intratympanic gentamicin (ITG) 6 to 8 weeks before surgery and the home-based vestibular training. Control group (CG) underwent standard vestibular training program after the surgical procedure. All patients were examined with videonystagmography including air-calorics, video Head Impulse Test, and cervical Vestibular Evoked Myogenic Potentials and filled out a set of questionnaires before the prehabilitation (ITGG) and before the surgery (both groups). Subjective and objective assessments were evaluated at the hospital discharge and three months after surgery.
Results: ITG prehabilitation leads ipsilaterally to a significant aVOR reduction in all semicircular canals (p<0.05), the increase of the unilateral weakness in air calorics (p=0.026) and drop in the presence of cVEMPs (p=0.017). ITGG shows better results in Dizziness Handicap Inventory in three months follow up (p=0.039). These findings are consistent with the results in optokinetic testing, where in higher speeds (40deg/s) ITGG shows higher gain than the CG, even though the difference did not meet the statistical significance.
Conclusions: Preoperative ITG is a feasible procedure for reducing drop in peripheral vestibular function after VS resection, and improves quality of life.
The correlation between fear avoidance beliefs and physical activity in unilateral vestibulopathies
Lien van Laer1, Hanna Koppelaar - van Eijsden2, Ann Hallemans1, Vincent van Rompaey3, Tjard Schermer4, Tjasse Bruintjes2, Luc Vereeck1
1University of Antwerp, Department of Rehabilitation Sciences and Physiotherapy / Movant, Faculty of Medicine and Health Science, Belgium. University of Antwerp, Multidisciplinary Motor Centre Antwerp (M2OCEAN), Belgium
2Gelre Hospitals, Apeldoorn Dizziness Centre, The Netherlands. Leiden University Medical Center, Department of Otorhinolaryngology, The Netherlands
3Antwerp University Hospital, Department of Otorhinolaryngology and Head & Neck Surgery, Belgium
4Gelre Hospitals, Apeldoorn Dizziness Centre, The Netherlands. Radboud University Medical Center, Department of Primary and Community Care, Radboud Institute for Health Sciences, Nijmegen
Purpose: In patients affected by unilateral vestibulopathy (UVP), physical activity (PA) is recommended to stimulate central vestibular compensation. However, presence of fear avoidance beliefs might negatively influence PA. The objectives of this study were (1) to investigate the relation between fear avoidance beliefs and PA and (2) to compare PA levels between patients with UVP in the (sub)acute and chronic phase.
Methods: In this cross-sectional study, PA was measured in patients with UVP using a tri-axial accelerometer attached to the upper leg. Fear avoidance beliefs were quantified using the Vestibular Activities Avoidance Instrument (VAAI). The correlation between fear avoidance beliefs and PA was evaluated using regression analyses. Other potential influencing factors were also considered in the analyses.
Results: A total of 102 UVP-patients were included with 51 in the (sub)acute and chronic phase. The average age was 56.1 (SD 15.2) years and 57.8% was male. Participants with chronic UVP presented with lower sedentary time, higher standing time, higher vigorous PA and higher total PA compared to participants with (sub)acute UVP. In participants with (sub)acute UVP, variability in total PA was explained up to 54.7% by fear avoidance beliefs, etiology of the UVP and gender (R2=0.547, F4,45=13.6 (p<0.001)). In participants with chronic UVP, fear avoidance beliefs explained 4.1% of the variability in total PA (R2=0.041, F1,49=2.086 (p=0.155).
Conclusions: In patients with (sub)acute UVP, assessing fear avoidance beliefs helps understanding physical inactivity. In patients with chronic UVP, no significant association between fear avoidance beliefs and PA was observed.
The Impact of Sleep Deprivation on Vestibular Adaptation
Hadas Ben Rubi Shimron1, Nir Livne2, Amit Wolfovitz2, Yoav Gimmon1
1University of Haifa, Department of Physical Therapy, Israel; Sheba Medical Center, Department of Otolaryngology, Israel
2Sheba Medical Center, Department of Otolaryngology, Israel
Purpose: Assessing the effect of sleep deprivation on the VOR and its adaptation abilities in acute and chronic sleep-deprived individuals.
Methods: Thirty-one healthy volunteers, 17 daytime and 14 healthcare night-shift workers (‘acute’ and ‘chronic’ groups respectively) were recruited. Participants were evaluated for two nights: (1) normal sleep; (2) 24-hour sleep deprivation for daytime workers or after a night shift. Tests included physiological VOR assessments using vHIT in four conditions randomly ordered: Far (150cm’) and near (15cm’) targets, performed with active (self-induced) and passive head movements. Adaptation ratio was calculated as the change between VOR gains in near and far target conditions.
Results: Twenty-five participants completed the protocol, fourteen from ‘acute’ and 11 from ‘chronic’ group. For daytime group VOR gain adaptation decreased following sleep deprivation by 5% and 7.1% for passive and active conditions, respectively. However, only active adaptation was reduced significantly. An increase in the VOR gain in the middle of the night was indicated. For night-shift group, no differences were found in vestibular adaptation between any condition. However, VOR gain was significantly lower following the night shift in passive far target condition.
Conclusions: Acute sleep deprivation spares VOR's physiological function but hampers adaptation, while chronic sleep deprivation compromises passive VOR function yet appears to maintain adaptation. This might imply an accumulating effect of sleep deprivation on a higher-level processing of the vestibular adaptation mechanism. Circadian rhythm involvement might explain the increase in VOR gain during the night. Dexterity high-risk tasks should be avoided after a sleepless night.
Use of a Head-Mounted Guidance System with Visual Feedback to Improve Outcomes in BPPV Treatment
Rajneesh Bhandari1, Anita Bhandari1, Herman Kingma2, Raymond van de Berg2
1NeuroEquilibrium
2Maastrich University, Netherlands
Purpose: The aim of this study was to describe a head-mounted benign paroxysmal positional vertigo guidance system to measure the head orientation and show the variability in head angulation during the canalolith repositioning maneuvers.
Methods: A guidance system for benign paroxysmal positional vertigo was developed by NeuroEquilibrium Diagnostic Systems to measure head orientation and provide visual feedback and instructions to examiners during various maneuvers for benign paroxysmal positional vertigo. Twenty-five experienced examiners and 25 healthy volunteers (aged 21-35 years) were recruited. Each examiner applied the Epley maneuver twice in 1 volunteer: without and with the use visual feedback from a guidance system. Head orientation in both procedures was measured and compared.
Results: The trained examiners demonstrated a large variability in head orientation during the Epley maneuver, which was reduced by using the benign paroxysmal positional vertigo guidance system. There was a variability of 39-65° in head orientation measured without the guidance system. The use of the guidance system reduced the variation range to a sixfold decrease in variability.
Conclusions: There is a large variability in head orientation when performing repositioning maneuvers, which could compromise the efficacy of benign paroxysmal positional vertigo treatment. Treatment for benign paroxysmal positional vertigo can be optimized by reducing this variability with a benign paroxysmal positional vertigo guidance system which provides visual feedback. It might also be a useful tool for teaching.
Vestibular rehabilitation using virtual reality in patients after vestibular schwannoma surgery
Zuzana Balatková1, Markéta Bonaventurová1, Květoslav Červený1, Rudolf Černý2, Vladimír Koucký1, Veronika Bandúrová1, Zdeněk Fík1, Martin Komarc3, Jan Plzák1, Zdeněk Čada4
1University Hospital Motol, Charles University Prague, Department of ENT and head and neck surgery, 1st Faculty of Medicine, Czech Republic
2University Hospital Motol, Charles University Prague, Department of neurology, 2nd Faculty of Medicine, Czech Republic
3Charles University Prague, Department of Anthropomotorics and Methodology, Faculty of Physical Education and Sport, Czech Republic
4University Hospital Motol, Charles University Prague, Department of otorhinolaryngology, 2nd Faculty of Medicine, Czech Republic
Purpose: Vestibular schwannoma surgery leads to an acute unilateral peripheral vestibular loss, immediately after the surgery the process of central compensation of vestibular disorder begins. The process of compensation is supported by vestibular rehabilitation. Our objective is to evaluate the effect of vestibular rehabilitation using virtual reality compared with standard vestibular procedures.
Methods: Prospective single-centre study was conducted, 52 consecutive patients underwent vestibular schwannoma based vestibular training. Control group underwent standard vestibular training program after the surgical procedure. Vestibular rehabilitation group had in addition minimum 210 minutes long vestibular training in virtual reality space in the first ten postoperative days. All patients were examined with videonystagmography including air-calorics, video Head Impulse Test, and cervical Vestibular Evoked Myogenic Potentials and filled out a set of questionnaires before the surgery. Subjective and objective assessments were evaluated at the hospital discharge and three months after surgery.
Results: Virtual reality group shows significantly better results in DHI and its functional subscale than control group in three months follow up. Exposure to virtual reality had a positive impact on subjective perception to complex visual and auditory stimuli in long term follow up. There were higher gains observed in optokinetic testing (40°/s) in virtual reality group compared with control group in long term follow up.
Conclusions: Postoperative virtual reality stimulation improves patients´ subjective perception of dizziness after vestibular schwannoma resection in long term follow up.
24. Vestibular Migraine
A Placebo Controlled, Randomized Clinical Trial of Galcanezumab for Vestibular Migraine: The INVESTMENT Study
Jeffrey Sharon1, Roseanne Krauter1, Ricky Chae2, Adam Gardi3, Maxwell Hum4, Isabel Allen5, Morris Levin6
1University of California, San Francisco, Department of Otolaryngology- Head and Neck Surgery, USA
2University of Massachusetts, Department of Medicine, USA
3Drexel University, Department of Medicine, USA
4McGovern University, Department of Medicine, USA
5University of California, San Francisco, Department of Epidemiology and Biostatistics, USA
6University of California, San Francisco, Department of Neurology, USA
Purpose: To investigate the effectiveness of a CGRP-targeted monoclonal antibody for vestibular migraine.
Methods: Single site, prospective, double-blind placebo controlled randomized clinical trial. Subjects aged 18-75 with a diagnosis of vestibular migraine or probable vestibular migraine per Barany society criteria were eligible. Outcome measures included: change in pre and post treatment score in VM-PATHI (Vestibular Migraine Patient Assessment Tool and Handicap Inventory), DHI (Dizziness Handicap Inventory), and count of Definite Dizzy Days (DDDs). The intervention was three months of treatment with galcanezumab or placebo.
Results: 38 subjects were included in the intent to treat analysis. VM-PATHI score was reduced 5.1 points (95% CI -13.0 to 2.7) in those randomized to placebo, and 14.8 points (95% CI -23.0 to - 6.5) in those randomized to galcanezumab (one tailed t-test, p=0.04). DHI dropped 8.3 points in the placebo arm (95% CI -15.0 to 1.6), and 22.0 points in the galcanezumab arm (95% CI -31.9 to - 12.1) (two tailed t-test p=0.018). The count of DDDs per month dropped from 18 days (SD 7.6) in the baseline month to 12.5 days (SD 11.2) in month 4 for those in the placebo arm, and from 17.9 days (SD 7.9) in the baseline month to 6.6 days (SD 7.3) in month 4 for those in the galcanezumab arm (two tailed t-test p = 0.026).
Conclusions: Galcanezumab is effective in treating vestibular migraine.
Altered cerebral blood flow and resting-state functional connectivity in patients with vestibular migraine
Zhengwei Chen1, Liangqun Rong1, Lijie Xiao1, Haiyan Liu1, Xiu-e Wei1, Yueji Liu1
1The second affiliated hospital of Xuzhou medical university, Department of neurology, China
Purpose: To investigate alterations of cerebral blood flow (CBF) and functional connectivity (FC) in patients with vestibular migraine (VM).
Methods: We evaluated 52 VM patients and 46 healthy controls (HC) who received pseudo-continuous arterial spin labeling (pc-ASL) and resting-state functional magnetic resonance imaging (rs-fMRI) scanning. Comparisons of voxel-based CBF and seed-based FC were performed between VM and HC. Brain regions showed significant group differences in CBF analyses were chosen as seeds in FC analyses. Additionally, the associations between abnormal imaging results and clinical features were further explored.
Results: Compared with HC, VM patients showed higher normalized CBF in brain regions of right precentral gyrus (PreCG), left postcentral gyrus (PostCG), left superior frontal gyrus and bilateral insular. In addition, we observed decreased FC between left insular and regions of left thalamus and right anterior cingulate cortex, as well as increased FC between left insular and right fusiform gyrus in VM patients. Furthermore, VM patients exhibited increased FC between right PreCG and areas of left PostCG, left cuneus and right lingual gyrus (LG). Normalized CBF in left PostCG was positively correlated with the frequency of migraine symptoms (p= 0.001, r= 0.475) and normalized CBF in left insular was positively correlated with the frequency of vestibular symptoms (p= 0.006, r= 0.407). Additionally, FC between left insular and left thalamus was negatively correlated with the duration of vestibular migraine (p= 0.011, r= -0.352) and FC between right PreCG and right LG was positively correlated with the frequency of vestibular symptoms (p= 0.012, r= 0.377).
Conclusions: Patients with VM during interictal period showed increased CBF in frontal and insular cortex and exhibited abnormal FC among vestibular, visual and sensorimotor cortex. These findings potentially help better understand the neuropathological mechanisms of VM.
Analysis of etiology and clinical features of spontaneous downbeat nystagmus: a retrospective study
Sai Zhang1, Yilin Lang1, Wenting Wang1, Yuexia Wu1, Shuangmei Yan1, Ting Zhang1, Dong Li2, Shaona Liu2, Yongci Hao1, Xu Yang3, Ping Gu1
1Department of Neurology, The First Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
2Vertigo Center of the First Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
3Department of Neurology, Peking University Aerospace School of Clinical Medicine, Beijing, China
Purpose: To investigate the topical diagnosis, possible etiology and mechanism of spontaneous downbeat nystagmus (DBN) patients with dizziness/vertigo.
Methods: The clinical features of dizziness/vertigo patients accompanied with DBN were retrospectively reviewed in the Vertigo Center of our hospital from January 2018 to March 2021. The clinical features of dizziness/vertigo patients accompanied with DBN were reviewed. Comprehensive VNG, bithermal caloric testing, vHIT, VEMP, radiography and other examinations were to determine the lesion site, and analyze its possible etiology and mechanism.
Results: A total of 54 patients were included. Among them, 70.4% were diagnosed with episodic vestibular syndrome, 22.2% with chronic vestibular syndrome, and 7.4% with acute vestibular syndrome. Among all the patients, 51.9% had clear etiology, with central lesions of 29.6% and peripheral diseases of 22.2%. The most common diseases were cerebellar lesions (13.0%,) and vestibular migraine (13.0%), follwed by BPPV(7.4%) and drug-related (5.6%). The other 48.1% of the patients had unknown etiology. 53.8% of patients with idiopathic DBN had decreased semicircular canal function, with 42.9% decreased posterior semicircular canal function. The posterior semicircular canal gain in DBN patients decreased compared to the anterior semicircular canal in the same conjugate plane. Patients with peripheral DBN were more prone to horizontal/torsional nystagmus during positional testing.
Conclusions: DBN patients have a relative decrease in posterior semicircular canal gain. The changes in nystagmus during positional testing may be helpful in distinguishing between peripheral and central causes.However,Cerebellar lesions may present peripheral-like manifestations, and that DBN in VM patients may be more related to the vestibular cortical center.
Designed the VM-targeted high-throughput sequencing panel and Identified the pathogenic gene
Zhanguo Jin1, Fengyuan Gong1
1Air Force Medical Center of Chinese PLA, Balance Disorders medical Center, China
Purpose: VM-targeted high-throughput sequencing susceptibility gene screening in Vestibular Migraine dissemination cases.
Methods: VM dissemination cases and control cases were collected, and the candidate gene set was screened through literature search, and the VM-targeted high-throughput sequencing panel (VM-Panel) was designed to target its coding region, and sequenced for both groups. Relevant genes were screened by comparing the frequencies of variants in the two groups, and their possible effects on VM were verified by animal experiments.
Results: In the disseminated case study, we obtained the VM frequency differential gene TPP4 by targeted high-throughput sequencing and bioinformatic analysis, and animal experiments showed that TPP4 inhibitors/agonists enhanced/relieved migraine-related behavioural activities in mice during part of the time period, and a certain degree of effect was observed in the geotaxis test to assess vestibular function.
Conclusions: VM may be a polygenic disease caused by the involvement of several susceptibility genes or external factors, and TPP4, as a susceptibility gene, may be involved in the development of migraine and vestibular symptoms in VM.
Evaluating the Efficacy of CGRP-Based Therapies in Treating Vestibular Migraine
Vishal Pawar1, Haripriya G R2, Aishwarya Pawar3, Mohammad Shouka3
1Dubai. UAE
2Institute of ENT, ENT department, India
3Dubai, UAE
Purpose: This study aims to assess the effectiveness of calcitonin gene-related peptide (CGRP) based therapies in treating vestibular migraine (VM), a neurological condition characterized by migraine and vestibular disturbances. By exploring these therapies, the study seeks to address the significant gap in targeted treatments for VM.
Methods: A retrospective observational cohort study in patients diagnosed with VM were treated with CGRP-based therapies, namely Erenumab, Rimegepant, and Eptinezumab. Outcomes were assessed using the Migraine Disability Assessment Score (MIDAS), Dizziness Handicap Inventory (DHI), and a visual analogue scale (VAS) for headache and vestibular symptoms, measured at baseline and after three months of therapy.
Results: Post-treatment evaluations demonstrated significant improvements; MIDAS scores, DHI scores, and VAS scores for headache and dizziness symptoms also showed considerable improvement. These findings suggest that CGRP-based therapies can substantially alleviate both headache and vestibular symptoms in VM patients.
Conclusions: The study underscores the potential of CGRP-based therapies in significantly enhancing the quality of life for patients suffering from VM. Given the chronic and debilitating nature of VM and the limited effectiveness of current treatment modalities, the introduction of CGRP-based therapies could represent a pivotal advancement in clinical practice. This supports the need for further clinical trials to validate these findings and possibly incorporate these therapies into standard VM treatment protocols.
Phenotypes of Vestibular Migraine: a cross sectional study ith clustering analysiss
Roberto Carlo Teggi1, Augusto Pietro Casani2, bruno colombo2, iacopo cangiano2, Giacinto Asprella Libonati2
1SIRCCS San Raffaele, Milano, Italy; “Vita e Salute” University
2Italia
Purpose: Phenotypes of vertigo attacks in definite Vestibular Migraine may vary from minutes to days and accompanying symptoms include migrainous headache and\or photo and phonophobia.
The aim of the study has been to collect a wide sample of definite VM phenotypes recruited in different italian centres and try to differentiate subtypes of patients with peculiarities.
Methods: We enrolled in different italian Universities the phenotypes of 244 VM subjects.
All of them performed a full bedside examination, an audiometric exam, a CNS MRI.
Patients presenting a low frequences hearing loss on one side outside vertigo spell were excluded. Patients were asked to characterize their symptoms and accompanying symptoms according to the proposed Barany Society grid of symptoms. We carried out a two-step cluster analysis using log-likelihood distance measures, which can detect relationships within a complex dataset between patients with multiple distinct characteristics.
Results: We have identified 5 clusters:
• Cluster 1 \ Group 1 (23 subjects, 9.4%) characterized by longer duration of vertigo attacks
• Cluster 2 \ Group 2 (52 subjects, 21.3%) characterized by absence of migrainous headache and cochlear symptoms during vertigo
• Cluster 3 \ Group 3 (44 subjects 18%) characterized by presence of cochlear symptoms during vertigo
• Cluster 4 \ Group 4 (57 subjects, 23.4%) by the presence of both cochlear symptoms and migrainous headache during vertigo
• Cluster 5 \ Group 5 (68 subjects, 27.9%) characterized by migrainous headache but no cochlear symptoms during vertigo
Each group present peculiarities for familial case of vertigo and headache, age of onset of vertigo and described vertigo (internal\external\dizziness)
Conclusions: VM is with any evidence an heterogeneous disorder and clinical presentation exhibit a great variability. In VM both symptoms orienting toward a peripheral mechanism and central ones may cohexist.
Our study is the first published trying to characterize subgroups of VM subjects, thus orienting toward different pathophysiological mechanisms.
The CGRP antagonist olcegepant does not block motion-induced nausea in mice lacking CGRP-Receptor Component Protein
Shafaqat Rahman1, Ian Dickerson1, Anne Luebke1
1University of Rochester Medical Center, Rochester, NY 14642 USA
Purpose: Migraine and vestibular migraine (VM) are disorders associated with heightened motion sensitivity that lead to symptoms of motion-induced nausea. Therapeutics blocking CGRP and its receptor have been proven effective to reduce migraine nausea. However, 40% of patients are unresponsive to these new drugs, suggesting there may be other targets. The receptor for CGRP consists of three complexed proteins, i) CLR, ii) RAMP1, and iii) CGRP-Receptor Component Protein (RCP). While current therapies have focused on antagonizing CGRP or CLR/RAMP1 complex we investigated what the loss of CGRP-RCP would have on a motion-induced nausea pain.
Methods: We have generated mice with a loxP conditional knockout of the 2ndexon of the Crcp gene. We then crossed these Crcp-loxP mice with nestin-CreERmice, resulting in mice with blocked neuronal RCP expression following tamoxifen induction. Tamoxifen-induced Crcp-loxP mice not expressing Cre served as controls. Both groups of mice were tested after tamoxifen induction in an assay of motion-induced nausea. Mice were assessed after intraperitoneal (IP) injections of: i) vehicle-PBS, ii) CGRP (0.1 mg/kg), or iii) CGRP (0.1 mg/kg) co-delivered with either olcegepant (1.0 mg/kg-CGRP-receptor antagonist) or rizatriptan (1.0 mg/kg-selective serotonin receptor agonists).
Results: We observed that CGRP increased motion-induced nausea, and that olcegepant (but not rizatriptan) was able to mitigate CGRP’s effect in tamoxifen-treated control mice (n = 11F/11M). Interestingly, floxed CGRP-RCP null (-/-) mice responded similarly as controls to CGRP, yet neither olcegepant nor rizatriptan mitigated CGRP’s effects (n = 11F/11M).
Conclusions: In summary, our findings show that: i) systemic CGRP increased motion-induced nausea in both control and mice lacking neuronal CGRP-RCP; and ii) loss of intracellular CGRP-RCP can render the CLR/RAMP1 complex insensitive to olcegepant, showing antagonist bias at the CGRP receptor.
Acknowledgements: This research is supported by a NIH R01 DC017261 (AEL) and University of Rochester SPIN grant (IMD).
Validation of vestibular migraine via analysis of individual attacks and course of illness
Scott Eggers1, Jeffrey Staab2, Joanna Jen3, Honghu Liu4, Deanna Hofschulte5, Roxana Gonzalez6, Neil Shepard7, Devin McCaslin8, Robert Baloh6
1Mayo Clinic in Minnesota, Department of Neurology, USA
2Mayo Clinic in Minnesota, Departments of Psychiatry and Psychology and Otorhinolaryngology - Head and Neck Surgery, USA
3Icahn School of Medicine at Mount Sinai, New York, Department of Neurology, USA
4University of California, Los Angeles, Fielding School of Public Health, Department of Biostatistics, USA
5Mayo Clinic in Minnesota, Department of Psychiatry and Psychology, USA
6University of California, Los Angeles, David Geffen School of Medicine, Department of Neurology, USA
7Mayo Clinic in Minnesota, Department of Otorhinolaryngology - Head and Neck Surgery, USA
8University of Michigan, Ann Arbor, Department of Otolaryngology - Head and Neck Surgery, USA
Purpose: To address concerns about the diagnostic validity of vestibular migraine raised by previous reports of broad heterogeneity of symptoms, this study critically analyzed characteristics of individual attacks and course of illness.
Methods: Patients with vestibular migraine (probable excluded) who were enrolled in a placebo-controlled randomized clinical trial recorded details of up to 2 attacks during diagnostic observation (no study drug) and up to 3 attacks during treatment (rizatriptan 10 mg or placebo). Patients rated severity of headache, vertigo, unsteadiness/dizziness, motion sensitivity, photophobia/phonophobia, and nausea/vomiting on a scale of 0 (absent), 1 (mild), 2 (moderate), or 3 (severe) at onset of attacks and at 0.5, 1, 2, 4, 24, and 48 hours thereafter.
Results: 222 adults (70.7% female, 42.5±11.7 years of age) reported 622 attacks over 3 months to 5 years. Median attack duration was 24 hours (range 1-216 hours). Mean symptom severity peaked at 1-2 hours and diminished through 48 hours. Median inter-attack interval was 23 days (range 1-642 days). Factor analysis identified a single factor including all symptoms at each time point. Cluster analyses at onset and peak severity revealed four patterns of attacks: (1) acute onset of moderate-to-severe headache with moderate-to-severe vertigo and unsteadiness/dizziness that continued to peak (15.9% of attacks), (2) acute onset of mild headache with moderate-to-severe vertigo and unsteadiness/dizziness that continued to peak (18.3%), (3) acute onset of mild-to-severe headache without vertigo, but moderate-to-severe unsteadiness/dizziness that continued to peak (17.7%), and (4) gradual onset of mild-to-severe headache with mild vertigo and unsteadiness/dizziness that continued to peak or transitioned into patterns 1, 2, or 3 at peak (31.7%). Use of study medication did not affect these patterns.
Conclusions: Findings of a single factor and distinct patterns of migrainous and vestibular symptoms during attacks support the current conceptualization of vestibular migraine. Course of illness was consistent with other migraine disorders.
VESTIBULAR MIGRAINE - What differs in this migraine phenotype
Maria Dolores Villar-Martinez1, David Moreno-Ajona1, Peter J Goadsby1, Adolfo M Bronstein2
1King's College Hospital London, Headache Team, UK
2Charing Cross Hospital London, Department of Brain Sciences, UK
Purpose: Research in vestibular migraine (VM) is increasing exponentially. Despite technological advances the clinical history still is the most powerful diagnostic tool – here we investigate 1) whether patients recruited in different clinical settings differ, 2) associated co-morbities, 3) treatments used and clinical outcomes.
Methods: We retrospectively assessed all cases diagnosed as VM (n=675) in Headache, Neuro-Otology (NO) and General Neurology (GN) clinics during 2021-23. Demographics, clinical history, treatment and outcomes were compared statistically.
Results: Patients were 77% females, older in NO than in GN clinics (median age 48.7 vs 35.8 respectively; P=0.031); discharge rate was 18% vs 55% respectively. Treatment choices were similar in NO and GN, prescribed in 77% of NO and 59% of GN patients (NS). Associated co-morbidities, as described in medical records or self-reported were compared in 340 VM and 185 chronic migraine (CM) – POTS (postural tachycardia syndrome), autoimmune conditions and hypermobility were higher in VM (5.4% vs 2.4%, χ2=3.47, P=0.05; 35.7% vs 24.7%, χ2=7.06, P<0.01; 4.4% vs 3.8%, χ2=0.07, NS, respectively). POTS (B=1.08, P=0.045) and autoimmune conditions (B=0.53, P=0.01) were significant predictors of VM. Medication overuse was slightly higher in patients who reported dizziness (24% vs 20%, NS) but paracetamol was a predictor for vertigo (N=96, B=0.56, P=0.045).
Conclusions: VM patients seen in NO are older (peri-menopausal) than in GN clinics – likely underlying neuro-otologists’ impression that VM starts in the perimenopause. Patients in NO clinics seem more severely affected, requiring more preventive treatment and follow-up. POTS, hypermobility and autoimmune conditions have a higher prevalence in VM than CM patients. Paracetamol use is a statistical predictor of vertigo but it is unclear if it is the drug or the headaches that contribute to the patient’s dizziness.
25. Vestibular Neuritis
A Machine Learning Model for Separation of Stroke from Vestibular Neuritis using the Video Head Impulse Test
Chao Wang1, Jeevan Sreerama1, Benjamin Nham1, Nicole Reid2, Nese Ozalp3, James Thomas3, Cecilia Cappelen-Smith4, Zeljka Calic4, Andrew Bradshaw2, Sally Rosengren1, Gülden Akdal5, Gabor Halmagyi1, Mukesh Prasad6, Gnana Bharathy6, Miriam Welgampola1
1University of Sydney, Central Clinical School, Australia
2Royal Prince Alfred Hospital, Institute of Clinical Neurosciences, Australia
3Liverpool Hospital, Department of Neurophysiology, Australia
4University of New South Wales, South Western Sydney Clinical School, Australia
5Dokuz Eylül University Hospital, Department of Neurosciences, Turkey
6University of Technology Sydney, School of Computer Science, Australia
Purpose: Acute Vestibular Syndrome, a sudden severe episode of vertigo and imbalance lasting 24 hours or longer, usually represents either Vestibular Neuritis (VN), an innocuous viral illness, or Posterior Circulation Stroke (PCS), a potentially life-threatening event. The video head impulse test (VHIT), a quantitative measure of the vestibulo-ocular reflex, helps distinguish between these two diagnoses. It can be performed by a technician at the bedside but requires interpretation by an expert clinician. We evaluated if machine learning models could be trained to differentiate between VN and PCS using the VHIT.
Methods: We developed classification models from 14 different machine learning algorithms trained on unprocessed head and eye velocity traces generated during video head impulse testing. Acute VHIT data from patients who presented with acute vestibular syndrome to an Emergency Room linked to a neuro-otology facility and whose final diagnosis was VN or PCS were used for training. Model performance was evaluated using an independent test dataset collected at a second institution using the same criteria.
Results: The training dataset comprised 257 patients from the first institution and the test dataset included 49 patients from the second institution. The best-performing model used the ROCKET algorithm and identified VN with 93% accuracy on the training dataset and 84% accuracy on the test dataset. Four blinded expert clinicians viewing the same VHIT test dataset identified VN with 84-88% accuracy. When models were developed on pooled patients from both institutions with an 80-20 train-test split, the model which used the Arsenal algorithm reached 92% accuracy on the test dataset.
Conclusions: A machine learning model can effectively differentiate PCS from VN using only VHIT data, with comparable accuracy to an expert clinician. It holds promise as an Emergency Room tool which could assist non-expert frontline physicians in evaluating patients with acute vestibular syndrome.
A potential biomarker for handicap severity in subacute dizzy patients: The gaze position error in video head impulses
Athanasia Korda1, Thomas Wyss1, Ewa Zamaro1, Efterpi Michailidou1, Tom Gawliczek1, Franca Wagner2, Marco Caversaccio1, Georgios Mantokoudis1
1Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
2University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
Purpose: This study aims to investigate the significance of gaze position error (GPE) following rapid head movements in the recovery of symptoms among patients with acute unilateral vestibulopathy (AUVP).
Methods: We studied patients 26 with AUVP and a control group of 48 healthy subjects. All patients received a video head impulse test (vHIT) during the acute stage and a follow-up vHIT 30 days after symptoms onset. Additionally, they completed a Dizziness Handicap Inventory (DHI) questionnaire.
Results: Based on our normative data we found a cut-off amplitude of 4° for abnormal GPE. Mean DHI score was 26.7 (+/- 28.9 SD). Seventeen patients had a mild, four had a moderate and five a severe dizziness handicap. DHI was highliy correclated with GPE (adjusted R2=0.446) and with the vestibulo-ocular reflex (VOR) gain (adjusted R2=0.272). Although age and gender were not significantly associated with DHI, there was a trend towards lower DHI scores in males. In the subscale analysis we found a marginal correlation between females and emotional DHI subscores and between age and functional DHI subscores (p<0.05).
Conclusions: Our study revealed a correlation between gaze position error (GPE) during rapid head movements and subacute symptoms following AUVP, explaining nearly 50% of the variance in Dizziness Handicap Inventory (DHI) scores. Additionally, emotional symptoms exhibited a gender bias, predominantly affecting females, while functional symptoms showed a slight dependence on age. The GPE has the potential to serve as an objective biomarker for symptom and handicap severityin dizzy patients.
A study on the lesion site and possible etiology of Acute unilateral peripheral vestibular dysfunction (AUPVD)
Yanhan Zhu1, Guo Qian1, Wenjing Qin1, Liying Chang1
1Department of Neurology, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science.
Purpose: To investigate the lesion site and possible etiology of AUPVD.
Methods: 94 patients hospitalized who met the inclusion criteria were retrospectively analyzed, with a mean age of 58 ± 15 years, and a male-to-female ratio of 2:1. The patients' Vestibular function tests results were analyzed;23 patients underwent labyrinthine gadolinium contrast enhancement, and we analyzed their image shadows; the efficacy was evaluated by DHI before the treatment and at the 3rd day of the treatment, and the basic information, cerebrovascular risk factors, BMI,Laboratory indicators were analyzed and compared.
Results: All 94 patients underwent vHIT, and 76 patients had abnormal results, of which 39 (51%) had abnormalities of the horizontal semicircular canal only; 26 (34%) had abnormalities of the horizontal and anterior canals; 3 (4%) had abnormalities of the three canals. Enhanced signal of the vestibular labyrinth on the lesion side was seen in some patients, but no enhanced signal of the vestibular nerve. After treatment, 59 cases (63%) had a better outcome, which have a significantly lower mean age, percentage of risk factors for cerebrovascular disease, and NLR values(P < 0.05).
Conclusions: Vestibular examination suggests that the lesion site did not follow the distribution of the supravestibular innervation pattern, and gadolinium contrast enhancement revealed that the abnormal signals were predominantly in the vestibular labyrinth, suggesting that the lesion site of AUPVD may have been the vestibular hair cells rather than the vestibular nerve. Vascular factors may also be one of the main etiologic factors of APVD.
Is Superior Vestibular Neuritis the Bell's Palsy of the VIIIth nerve?
Joel Goebel
1
1Washington University Shcool of Medicine, Department of Otolaryngology-Head and Neck Surgery
Purpose: This lecture proposes a novel hypothesis regarding superior vestibular neuritis and its comparison to idiopathic facial paralysis (Bell's palsy) on the basis of viral inflammation and anatomic features at the fundus of the internal auditory canal for both nerves on two histologic studies performed by the author's team.
Methods: Two histologic studies (Goebel JA, O’Mara W, Gianoli G: Anatomic Considerations in Vestibular Neuritis. Otol Neurotol, 22:512-518, 2001. PMID: 11449110 and Gianoli G, Goebel JA, Mowry S, Poomipannit P: Anatomic Differences in the Lateral Vestibular Canals and their Implications in Vestibular Neuritis. Otol Neurotol 26(3), pp. 489-494, 2005. PMID: 15891655) were performed to analyze the difference in the superior versus inferior vestibular nerve pathways through the temporal bone at the fundus of the lateral internal auditory canal to the endorgans. The literature was searched to develop the hypothesis of HSV-1 viral inflammation leading to neural swelling and entrapment and ischemia of the superior vestibular nerve in similar fashion to to the suspected entrapment of the facial nerve in Bell's palsy.
Results: Both histologic studies identified statistically longer and narrower pathways of the superior in comparison to inferior vestibular nerves. In addition, the arteriolar bony channels were smaller along the superior versus inferior vestibular nerve. The literature was then reviewed to investigate the hypothesis of HSV-1 inflammation as a cause of neural edema, compression and, in some cases, compromise of the vasa nervorum leading to downstream damage of the endorgans of the superior vestibular nerve. Finally, these findings were compared to historical evidence of HSV-1 involvement in the facial paresis/paralysis seen in Bell's palsy.
Conclusions: Based on temporal bone histologic studies in combination with historical evidence of HSV-1 involvement in both vestibular neuritis and Bells' palsy, a common theory of inflammation, entrapment and ischemia of the nerve and downstream neural elements is proposed.
No Effect of Corticosteroids on Acute Unilateral Vestibulopathy
Julia Sjögren1, Mikael Karlberg1, Måns Magnusson1, Per-Anders Fransson1, Fredrik Tjernström1
1Lund University
Purpose: Over the past two decades, studies have investigated the effectiveness of corticosteroid treatment for acute unilateral vestibulopathy (AUVP). While some studies have indicated reduced caloric side differences and shorter hospital stays in follow-up assessments, others have yielded conflicting results with no significant improvements observed in vestibular function or subjective distress. This study aimed to assess the short and the long-term effects of corticosteroid treatment on vestibular function and subjective well-being symptoms in patients with AUVP.
Methods: A double-blinded randomized placebo-controlled prospective study, patients with AUVP were enrolled within 48 hours of symptom onset. Controls received intravenous saline followed by oral placebo, while patients were administered intravenous betamethasone followed by oral corticosteroids. Symptoms were documented in a structured diary for the first 4 weeks and evaluated using the Dizziness Handicap Inventory (DHI) at 3 and 12 months. Vestibular function was assessed with the caloric test at disease onset and at 3 and 12 months, and the video head-impulse test (vHIT) at disease onset and at 1, 3, and 12 months.
Results: In the analysis of 69 patients, 45 received corticosteroid treatment. Both groups showed improved vestibular function over time, seen in enhancements in caloric responsiveness (p=0.014) and vHIT gain (p<0.001). Although corticosteroid treatment showed a trend toward improved caloric responsiveness, no significant differences were observed between the groups at any time point. Symptom reduction was significant in both groups during the first month, but no significant differences in symptom severity or resolution were observed between the groups. Subjective dizziness measured with DHI did not differ between the groups at 3 and 12 months.
Conclusions: Corticosteroid treatment does not seem to enhance functional recovery in a major way or alleviate symptom severity in the short- or long-term aspect of AUVP.
Trial registration number: EudraCT 2014-005484-32
Predicting chronic dizziness in acute unilateral vestibulopathy by using patient-reported outcomes
Lien Van Laer1, Vincent Van Rompaey2, Ann Hallemans3, Luc Vereeck3
1Department of Rehabilitation Sciences and Physiotherapy / Movant, Faculty of Medicine and Health Science, University of Antwerp, Antwerp, Belgium; Multidisciplinary Motor Centre Antwerp (M2OCEAN), University of Antwerp, Antwerp, Belgium; Department of Otorhinolaryngology and Head & Neck Surgery, Antwerp University Hospital, Antwerp, Belgium
2Department of Otorhinolaryngology and Head & Neck Surgery, Antwerp University Hospital, Antwerp, Belgium; Department of Translational Neurosciences, University of Antwerp, Antwerp, Belgium
3Department of Rehabilitation Sciences and Physiotherapy / Movant, Faculty of Medicine and Health Science, University of Antwerp, Antwerp, Belgium
Purpose: This prospective study aimed to establish cut-off values for patient-reported outcomes measured at 10 weeks post-onset to predict chronic dizziness in acute-unilateral vestibulopathy (AUVP)
Methods: Participants with AUVP were included based on the criteria of the Barany society and evaluated at 10 weeks post-onset. Receiver operating characteristic (ROC) curves were used to determine cut-off values on the Vestibular Activities and Avoidance Instrument (VAAI), Visual Vertigo Analog Scale (VVAS), and Hospital Anxiety and Depression Scale-Anxiety/Depression (HADS-A/D) to predict a Dizziness Handicap Inventory (DHI) score > 30 at six months.
Results: A total of 103 participants were included with a mean age of 55.2 ± 16.6 years of which 49 (47.6%) were women. Cut-off values (with accompanying area under the curve (AUC) values and sensitivity and specificity percentages) were established for the VAAI >23/54 (AUC: 0.874 (p<0.001; {0.739;1.010} 95% Confidence Intervals (CI)); 92.3% sensitivity and 78.7% specificity); the VVAS >33.5/100 (AUC: 0.852 (p<0.001; {0.728;0.977} 95%CI); 84.6% sensitivity and 84.3% specificity); the HADS-A >6.5/21 (AUC: 0.842 (p<0.001; {0.700;0.984} 95%CI); 76.9% sensitivity and 82.0% specificity) and the HADS-D > 4.5/21 (AUC: 0.856 (p<0.001; {0.749;0.963} 95%CI); 84.6% sensitivity and 76.4% specificity).
Conclusions: The identified cut-off values offer practical utility in clinical settings for early identification of chronic dizziness risk. Adjustment of management, such as intensifying and diversifying vestibular rehabilitation, at 10 weeks post-onset, holds potential promise in preventing chronic dizziness.
The vestibular-ocular reflex recovery after vestibular neuritis: a longitudinal study
Benjamin Nham1, Imelda P Hannigan2, Chao Wang3, Nicole Reid3, Allison S Young2, Andrew P Bradshaw3, Sally M Rosengren3, Shaun R Watson4, Miriam S Welgampola3
1St George and Sutherland Clinical School, University of New South Wales, Sydney, Australia
2Central Clinical School, University of Sydney, Sydney Australia
3Institute of Clinical Neurosciences, Royal Prince Alfred Hospital, Sydney, Australia
4Blacktown Neurology Clinic, Blacktown, NSW 2148, Australia
Purpose: We sought to prospectively examine video head impulse (vHIT) characteristics of acute vestibular neuritis (VN) on presentation and across multiple time-points over a six-month period.
Methods: Eighty-seven VN patients, recruited from the emergency-department, diagnosed using HINTS criteria, underwent serial vHIT at symptom onset, weekly for one-month and at six-months. Vestibulo-ocular reflex (VOR) gains of the ipsilesional semicircular canals (SCC) and catch-up saccade metrics were analysed.
Results: Superior, inferior, and pan-neuritis patterns were seen in 70%, 4% and 26%. Three or more serial vHIT recordings were performed on 88.5% of patients. The ipsilesional mean VOR gains at ictus were: 0.48±0.24, 0.52±0.25, and 0.71±0.20 for the horizontal, anterior, and posterior canals. By six-months, mean gains were 0.80±0.23, 0.82±0.20 and 0.77±0.15; consistent with normal control values. At week-one, of 8% with normal vHIT gains at ictus developed abnormal gains consistent with VN in total 14% had a further reduction in lateral-canal VOR gain of >0.1 at one-week follow-up. Since recovery of the SCCs was asynchronous, vHIT pattern atypical of VN occurred at one-week (26%), four-weeks (45%), and six-months (57%). 20% of patients had gain abnormalities not typical of VN during the study, with atypical patterns demonstrated at one-month (11%) and six-months (6%).
The lateral canal first saccade mean amplitude 4.8±2.5 degrees and prevalence 202±57% at ictus dropped to 109±62 degrees and 2.3±1.8% by six-months, with increased latency (168±59ms to 236±75ms). Significant changes in saccade metrics were observed for the lateral and anterior canals but not the posterior canals.
Conclusions: Comparison of SCC function at ictus and serially over six-months demonstrates complete recovery of VOR gain in 47%, identical patterns of dysfunction in 23% and atypical pattern of SCC dysfunction for VN during recovery in 20%. These observations will help guide clinicians faced with assessing patients with partially recovered VN.
Vestibular neuritis: Is there a comorbidity with migraine?
Michael von Brevern1, Hannelore Neuhauser2, Fabian Moser2, Kathrin Pahnke3, Thomas Lempert4
1Private Practice of Neurology, Berlin, Germany
2Robert Koch-Institut, Berlin, Germany
3GFO Kliniken Troisdorf, Department of Neurology, Germany
4Schlosspark-Klinik, Department of Neurology, Berlin, Germany
Purpose: Several disorders of the inner ear are associated with migraine. Thus far, the prevalence of migraine has not been examined in patients with vestibular neuritis.
Methods: 99 consecutive patients with vestibular neuritis (53 women, 46 men, age range 21-86 years) and 112 matched controls (55 women, 57 men, age range 20-88 years) were included in a prospective case-control-study. Vestibular neuritis was diagnosed based on the following criteria: (1) acute vestibular syndrome with spontaneous horizontal nystagmus, (2) no central neurological symptoms or signs, no acute hearing symptoms, (3) unilateral reduced vestibular response on caloric irrigation. Migraine was diagnosed in patients and controls using a semi-structured questionnaire based on the International Classification of Headache disorders.
Results: In women, migraine prevalence was 52.8% (95% CI 39.2-66.0) in cases and 29.1% (95% CI 18.4-42.7) in controls. In men, migraine prevalence was 43.5% (95% CI 29.7-58.3) in cases and 17.5% (95% CI 9.6-29.9) in controls. Migraine prevalence including probable migraine was 58.6% (95% CI 48.5-68.0) in cases and 26.8% (95% CI 19.3-35.8) among controls. In a logistic regression model adjusted for age, sex, diabetes, hypertension, hypercholesterinemia, smoking and previous stroke, the presence of migraine was associated with an OR for neuritis of 3.27 (95% CI 1.75-6.11). In a separate model with the same adjusting factors the presence of migraine including probable migraine was associated with an OR for neuritis of 4.42 (95% CI 2.35-8.32).
Conclusions: The life-time prevalence of migraine is increased in patients with vestibular neuritis. Migraine may be a risk factor for vestibular neuritis.
Wrong-Way Nystagmus In Acute Vestibular Disorders
Claire Allen1, Jorge Kattah2, Bernardo Faria Ramos3, Daniel Gold4
1Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
2Department of Neurology, University of Illinois College of Medicine at Peoria, Peoria, Illinois, USA
3Department of Otorhinolaryngology, Federal University of Espirito Santo, Vitoria, Brazil
4Department of Neurology, Neurosurgery, Ophthalmology, Otolaryngology - Head and Neck Surgery, Emergency Medicine, & Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
Purpose: Peripheral vestibular disorders classically present with contralesional (inhibitory) nystagmus (e.g., vestibular neuritis in the acute vestibular syndrome [AVS]), while ipsilesional (excitatory) nystagmus is less common (e.g., Ménière’s in the episodic vestibular syndrome [EVS]). In this study, we describe the clinical presentation and propose possible etiologies of ipsilesional nystagmus (IN) in peripheral vestibulopathies.
Methods: We describe three patients with IN. Evaluation included video head impulse testing (vHIT) and contrast-enhanced MRI.
Results: Case 1: EVS - Ménière’s syndrome Examined at 3.5 hours; left ear hearing loss and tinnitus; spontaneous IN unchanged with hyperventilation or head-shaking. Normal vHIT and MRI.
Case 2: AVS – unilateral 7
th
and 8
th
cranial neuropathies Examined on day 4 (day 10 of facial palsy); no aural symptoms; spontaneous IN increased with hyperventilation and head-shaking. Normal vHIT. MRI IAC - ipsilateral 7th& 8thenhancement.
Case 3: AVS - labyrinthitis from COVID infection Examined on day 1; left ear hearing loss and tinnitus; IN increased with head-shaking, unaffected by hyperventilation. Normal vHIT and MRI.
Conclusions: In Ménière’s, there is an initial excitatory (1st) phase, then a paralytic or inhibitory 2ndphase, then a recovery (3rd) phase (i.e., adaptive mechanisms and increased sensitivity of the vestibular nuclei on the paretic side). In Case 2, spontaneous IN could result from excitatory inflammatory and/or (viral) infectious phenomena and/or incomplete vestibulopathy (normal vHIT) with partial adaptation 4 days after onset. The significant hyperventilation-induced IN may suggest increased conductivity across an injured or demyelinated segment of CN8 (akin to vestibular schwannoma or vestibular paroxysmia). In Case 3, possible mechanisms include excitation and/or incomplete vestibulopathy (normal vHIT) with adaptation.
Ipsilesional nystagmus in the EVS and AVS probably results from excitatory and/or adaptive processes. The observation of IN in peripheral AVS confounds the bedside ocular motor and vestibular examination, but may shed light on the mechanism of injury and/or etiology.
26. Vestibular Prosthesis
Ambulant haptic stimulation improves Balance and Mobility in bilateral vestibular loss fast and long
Herman Kingma1, Raymond van de Berg2
1Dept. of ORL&HNS, Maastricht University Medical Center, The Netherlands and Balance & Dizziness Centre, Dept. of ORL&HNS, Aalborg University Hospital, Denmark
2Dept. of ORL&HNS, Maastricht University Medical Center
Purpose: Monitor the impact of ambulant haptic stimulation upon balance an mobility in patients with severe bilateral vestibular loss from 2 hours to 2 years of daily use.
Methods: Longitudinal study in patients with severe imbalance, poor mobility associated with severe bilateral vestibular loss, referred for ambulatory haptic stimulation. The prothesis uses vibratory stimulation provided by ten tactors built in a belt worn around the waist. A 6DOF sensor, mounted in the belt, detected trunk acceleration and tilt and coded this into specific vibration patterns around the waist by activating the tactors. Patients were instructed not to pay any attention to the stimulation to avoid cognitive load. Impact was assessed after 2 hours in the hospital, and after 2 weeks, 2 months, 1 year and 2 years of daily use at home. The impact was quantified by the Balance and Mobility score ranging from no balance or mobility (score 0) to the best personal balance and mobility as patients remembered from before the development of the symptoms (score 10). Only patients with a BMS≤5 were included.
Results: After 2 hours of use in 121 patients (BMS≤ 5), 89 patients experienced instantaneous improvement of BMS from average 3.8(SD=1.3) to 5.6(SD=1.6) and decided to try daily use at home. In 80 patients, improvement increased within two weeks and stabilised to 7.4(SD=1.3). All decided to keep using the belt daily. After 2 years 65 patients wore the belt daily (6 deceived, 9 were lost in follow up) and had improved their BMS by minimum two points, and reported no falls.
Conclusions: This study indicates that haptic stimulation can almost instantaneously improve balance and mobility in severe BVL patients and that the maximum positive effect is reached in 1 months and remains for at least 2 years. The prothesis is now evaluated in CI children with BVA too.
Bilateral vestibular stimulation from a combined vestibular and auditory prosthesis
James Phillips1, Leo Ling1, Yoshiko Kojima1, Jay Rubinstein1, Shawn Newlands2
1University of Washington
2University of Rochester
Purpose: Head movement modulated bilateral vestibular and auditory stimulation may offer benefits to patients with bilateral SNHL and vestibular loss. In this study we evaluated a novel bilateral vestibular prosthesis that was designed to deliver simultaneous stimulation to the ampullary and auditory nerves via an external processor with microphone and gyroscopic inputs. The purpose was to compare bilateral and unilateral stimulation in an animal model.
Methods: Rhesus monkeys were implanted bilaterally with a vestibular prosthesis targeting the ampulla of each semicircular canal. The implanted device had an additional cochlear lead with a 16-channel array. The monkeys were placed in a multi-axis rotator in a light tight booth and trained to track laser projected targets for a reward. Eye position was monitored with a 3d scleral coil. Frequency and amplitude modulated biphasic pulse stimuli were provided either with the head stationary (fictive rotation) or during en-bloc rotation either in the dark or with point or optokinetic visual targets. Stimuli were presented either unilaterally or bilaterally in different phase combinations.
Results: Bilateral stimulation was well tolerated by rhesus monkeys. Out of phase bilateral stimulation produced more directionally symmetric and higher slow phase velocity eye movements than unilateral stimulation, partially overcoming current limitations to conventional unilateral stimulation. Bilateral stimulation did not produce a linear summation of the response to unilateral stimulation of each ear alone. The phase relationship between stimuli had a strong correlation with the symmetry and velocity of the observed movement. Bilateral stimulation largely eliminated the need for complex combinations of acceleration and velocity inputs to produce natural vestibulo-ocular reflex (VOR) responses.
Conclusions: Bilateral vestibular prosthetic stimulation does appear to provide advantages over unilateral stimulation with respect to the overall efficacy of modulated bilateral pulse stimulation in creating a robust VOR.
Constant “baseline” electrical stimulation can improve function in patients implanted with vestibulo-cochlear implants
Gautier Grouvel1, Julie Corre1, Jean-François Cugnot1, Samuel Cavuscens1, Maurizio Ranieri1, Anissa Boutabla1, Raymond van de Berg2, Stéphane Armand3, Nils Guinand1, Angélica Pérez Fornos1
1University of Geneva and Geneva University Hospitals, Division of Otorhinolaryngology Head and Neck Surgery, Geneva, Switzerland
2Maastricht University Medical Center, Division of Balance Disorders, Department of Otorhinolaryngology and Head and Neck Surgery, Maastricht, the Netherlands
3University of Geneva and Geneva University Hospitals, Kinesiology Laboratory, Geneva, Switzerland
Purpose: Prototypes of vestibular implants are under development to rehabilitate patients with bilateral vestibulopathy (BV), mimicking the physiology of the vestibular system. An alternative and simplified approach consists in delivering only constant electrical stimulation to restore a “baseline” activity in the vestibular system. This study aimed to quantify the benefits of such a “baseline” stimulation (BS) delivered to semicircular canal afferents during prolonged periods of activation.
Methods: Two female patients with BV received a modified cochlear implant providing 3 extra-cochlear electrodes implanted in the semicircular canals. The patients’ speech processor was programmed to deliver a BS to the posterior semicircular canal for a period of 2.5 months. Objective and subjective measurements (gait analyses, questionnaires) were acquired throughout the stimulation period and afterwards over 6 sessions. DHI scores and number of steps for the tandem walk task were also analysed.
Results: For patient-1, DHI scores improved from 52 to 30 throughout the BS, reflecting clinically relevant changes. After BS deactivation, DHI score increased to 48, representing a decline of functional status. The number of steps in the tandem walk task increased from 2 to 10 steps. Results for patient-2 do not present any changes during the BS.
Conclusions: Results in at least one patient demonstrate that vestibular deficits were reduced during the BS, complemented by positive patient feedback: “the implant allows me to walk in a straight line”. Objective and subjective gains disappeared when BS was deactivated. While this stimulation shows promise, its effectiveness may vary among patients, highlighting the need for devices that employ stimulation methods closer to human physiology.
Delineating vestibular postural contributions, dynamics, and unilateral restoration
Bassil A Ramadan1, Olivia ME Leavitt Brown1, Kathleen E Cullen1
1Johns Hopkins University
Purpose: Despite significant efforts to restore function following vestibular loss via rehabilitation, bilateral vestibular loss patients remain at significant risk of falls. Vestibular prostheses offer an alternative which restores function by directly stimulating afferents. Here we examine how vestibular prostheses can restore balance in a Rhesus macaque model.
Methods: A head-mounted IMU measured angular and translational velocity of head response to tilt. Pressure plates reveal limb reaction forces. Taken together, we first examine baseline, intact monkeys to delineate the effects of platform dynamics, controlling for both peak velocity (20, 40, 60 deg/s at 500 m/s2) and the acceleration (200, 500, 1000 m/s2at 40 deg/s). Subsequently, we test the same dynamics after bilateral vestibular loss (BVL). Finally, we assess vestibular restoration through a unilateral multichannel vestibular prosthesis (MVP) using both linear pulse trains and biomimetic patterns.
Results: Study results demonstrate three key findings. 1) Platform acceleration, independent of peak velocity, effects postural compensation. 2) There are distinct departures of head dynamics and limb reflex in both axes post-BVL. 3) MVP implantation offers significant improvement in postural reflexes, with added benefit from the inclusion of biomimetic stimulation patterns.
Conclusions: Despite postural differences, Rhesus macaque mirrors dynamics of humans, offering a valuable model of disease. We now see an importance to assessing and controlling the platform motion profile in diagnostic and research assessments in humans. Finally, we provide initial evaluation of novel biomimetic stimulation for vestibular function recovery.
Dynamic Gait Index after otolith implantation
Angel Ramos Macias1, Morgana Sluydts2, Angel Ramos de Miguel3, Angel Ramos Macias1, Raquel Manrique4, Manuel Manrique4, Maurizio Barbara5, Andrzej Zarowski2
1Hearing Loss Unit, Otorhinolaryngology, Head and Neck Department, Complejo Hospitalario Universitario Insular Materno Infantil, Las Palmas of Gran Canaria, Spain
2European Institute for ORL-HNS, Belgium
3Hearing and Balance Laboratory, University of Las Palmas de Gran Canaria, Las Palmas, Spain
4Otorhinolaryngology department, Clinica Universidad de Navarra, Pamplona, Spain
5NESMOS department, ENT clinic, Sapienza University Roma, Italy
Purpose: The current standard-of-care for patients with bilateral vestibulopathy (BVP) is vestibular rehabilitation. However, the exercises in vestibular rehabilitation often fail to improve the vestibular performance and quality of life sufficiently. Therefore, the impact of a cochleo-otolith implant (CVI) on the dynamic gait index (DGI) was investigated.
Methods: A total of eleven adult patients suffering from severe to profound hearing loss and bilateral vestibulopathy were implanted with a CVI designed for simultaneous restoration of auditory and vestibular functions. A linear mixed model (LMM) analysis was performed on the scores of the DGI, which was performed before and after implantation (during five postoperative visits). The following terms were entered in the model: study visit (‘visit’), CVI ON or OFF (‘condition’), interaction effect ‘condition*visit’. The dependent variable was the total DGI score.
Results: The results of the LMM showed that there was a significant effect of ‘visit’ (F (5,41) = 6,651; p < 0,001) and ‘condition’ (F (1,42) = 22,785; p < 0,001). The results suggested that for each postoperative study visit, the total DGI score was better than the pre-operative score. Furthermore, a random effect was obtained (Wald Z = 2,244; p = 0,025; estimate = 8,9; standard error = 3,965; 95% confidence interval: [3,8; 21,0]) indicating that the individual DGI scores differed significantly between participants when the overall data was analyzed. By incorporating the repeated measures design (adding the ‘visit’ term), the significance of this effect disappeared, suggesting that all participants underwent similar changes through the study visits.
Conclusions: Electrical otolith (saccular) stimulation by means of a CVI significantly improved vestibular performance during the tasks of the dynamic gait index.
Effects of return electrode position on vestibular implants in humans
Evan O. Vesper1, Andrianna I. Ayiotis1, Margaret R. Chow2, Celia Fernandez Brillet1, Ruolan Sun1, Charles C. Della Santina3
1Johns Hopkins University, Department of Biomedical Engineering, USA
2Labyrinth Devices, LLC, USA
3Johns Hopkins School of Medicine, Department of Otolaryngology - Head and Neck Surgery, USA
Purpose: Recent work in rhesus macaques indicates that an intralabyrinthine return electrode provides focal stimulation of ampullary nerves without spreading current to the facial nerve. However, the optimal location for implantation of the Multichannel Vestibular Implant (MVI) return electrode has not yet been definitively determined. We seek to understand the effect of return electrode location to guide surgical approaches and minimize current spread to nontarget tissues, such as the facial and cochlear nerves.
Methods: Since 2016, 15 participants were implanted with the MVI. The first 7 participants have an intralabyrinthine return electrode and the remaining 8 have a distant return located subperiosteally, outside the temporal bone. All underwent an electrode characterization procedure 3 weeks post-implantation to determine the threshold currents up to 700 uA at 100 us/phase needed to elicit perception of head motion (Tp) and nontarget percepts (Tn).
Results: Tp was 320±130uA (mean±SD) for electrodes used with an intralabyrinthine return and 240±130uA for a subperiosteal return. Tn was 530±150uA for an intralabyrinthine return and 580±90uA for a subperiosteal return. However, within the maximum current range of 700 uA, implant recipients reported nontarget perceptions for only 20% of electrodes used with an intralabyrinthine return but 60% with a subperiosteal return. The nontarget percepts elicited by electrodes used with a subperiosteal return were auditory percepts (79%), facial twitches (23%), facial sensations (5%), and other discomfort (14%).
Conclusions: Consistent with the results found in non-human primates, intralabyrinthine return electrodes minimized symptoms and signs of current spread to nontarget structures but required more current to elicit vestibular percepts than did subperiosteal returns. Physiological responses, such as the electrically evoked vestibulo-ocular reflex and evoked compound action potentials, required surgical time, and nontarget percepts should all be considered to identify the ideal return electrode location. Support: NIDCD U01DC019364, NIA R01AG076701, NIH 2T32EB003383.
Interim Results After 1-7 Years of Continuous Daily Use of the Labyrinth Devices Multichannel Vestibular Implant
Charles C. Della Santina1, Margaret R. Chow2, Andrianna I. Ayiotis3, Celia Fernandez Brillet3, Desi P. Schoo4, Stephen Bowditch4, Evan Vesper3, Ruolan Sun3, Kelly Lane4, Claudia Lee4, Peter J. Boutros3, Brian J. Morris2, John P. Carey4, Bryan K. Ward4, Vestibular Implant Research and Development Teams5
1Johns Hopkins School of Medicine Department of Otolaryngology – Head & Neck Surgery; Johns Hopkins University Department of Biomedical Engineering; Labyrinth Devices, LLC
2Johns Hopkins University Department of Biomedical Engineering; Labyrinth Devices, LLC
3Johns Hopkins University Department of Biomedical Engineering
4Johns Hopkins School of Medicine Department of Otolaryngology – Head & Neck Surgery
5Labyrinth Devices LLC and MED-EL GmbH
Purpose: Describe interim results for the first-in-human clinical trial of long-term, continuously motion-modulated prosthetic stimulation using the MVI™ Multichannel Vestibular Implant System developed by Labyrinth Devices LLC and MED-EL GmbH.
Methods: Fifteen adults with bilateral vestibular hypofunction (8 ototoxic; 7 idiopathic/non-ototoxic/non-central) underwent unilateral implantation from August 2016 to February 2024. Duration from symptom onset to implantation ranged from 2-24 years. We assessed post-activation binocular 3-dimensional vestibulo-ocular reflex (3D VOR) responses to prosthetic stimulation and pre- to post-implantation changes in VOR responses to yaw, LARP and RALP head-on-body impulses and 0.1-2 Hz whole-body yaw rotation; pure tone and speech audiometry; dynamic visual acuity; clinical tests of posture and gait; and validated patient-reported outcome instruments for disability (Dizziness Handicap Inventory, Vestibular Activities of Daily Living) and health-related quality of life (SF36 and Health Utilities Index [HUI3]).
Results: Every implant recipient has used the system daily since device activation. Six wear it 24 hr/day; nine take it off while in bed. All but one have electrically-evoked VOR responses (typically ranging from ∼5-100°/s and aligned approximately with the stimulated canal) for at least one electrode for each implanted canal. Rotary chair VOR responses are greater with motion-modulated stimulation than without. Motion perception thresholds are below VOR thresholds. Hearing sufficient for unaided telephone use was preserved in 9 of 15 implanted ears. Posture, gait, dizziness handicap, vestibular disability and health-related quality of life (quantified by SF36-derived SF6D utility) improved significantly compared to preop for the group. HUI3, which more heavily weights hearing, did not significantly change.
Conclusions: Vestibular implantation can be performed as an outpatient surgery while preserving useful hearing. Motion-modulated input generates motion percepts and 3DVOR responses consistent with semi-selective stimulation of each implanted canal, improving postural stability, gait, patient-reported disability and quality of life.
Support: NIH R01DC13536, U01DC0019364; Labyrinth Devices LLC; MED-EL GmbH
Long-term outcomes for continuous vestibular stimulation: Posture, gait, dynamic visual acuity and cognitive load
Celia Fernandez Brillet1, Margaret R Chow2, Claudia N Lee3, Kelly E Lane3, Andrianna I Ayiotis1, Charles C Della Santina4
1Johns Hopkins University, Department of Biomedical Engineering, USA
2Labyrinth Devices, LLC, USA
3Johns Hopkins University, Department of Otolaryngology–Head & Neck Surgery, USA
4Johns Hopkins University, Departments of Otolaryngology–Head & Neck Surgery and Biomedical Engineering, USA
Purpose: Report changes in posture, gait and oscillopsia for 15 adults followed up to seven years after unilateral vestibular implantation for bilateral vestibular hypofunction (BVH). Examine effects of cognitive distraction on posture and gait during motion-modulated (treatment mode) and constant rate/amplitude (placebo) stimulation.
Methods: Assays included Modified Romberg on foam with eyes closed (MR), Bruininks-Oseretsky Test Balance Subtest (BOT-2), Dynamic Gait Index (DGI), Timed Up and Go (TUG), gait speed, and dynamic visual acuity (DVA). We administered TUG with and without distraction (serial sevens downward counting) to quantify effects of cognitive load on walking tasks. We assayed oscillopsia and DVA while patients walked on a treadmill at 0-3 mile/hr (mph), quantifying DVA performance using the slope of within-patient DVA decrease with increasing treadmill speed, with zero slope being normal and more negative slopes indicating worse performance.
Results: Within-participant MR standing time averaged across the group (mean (±SD)) increased by 9.9±11.9 seconds from pre-op to the most recent visit, with 5 patients post-operatively surpassing the 30-second maximum allowed score. BOT-2 scores improved by 3.2±5.4 points. Within-participant gait speed increased by 0.09±0.22 m/s. TUG without distraction improved by 2.5±2.3 seconds. DGI improved by 7.0±5.0 points. Compared to treatment mode, average within-participant changes during placebo mode stimulation were worse for all metrics. In the five patients tested with and without serial sevens counting, median cognitive load cost during TUG decreased from 19.4% (range [4.3-42.0%]) pre-operatively to 11.4% ([1.1-17.0%]) in placebo mode and 8.9% ([5.9-20.3%]) in treatment mode. In the eleven patients tested using treadmill DVA, group median DVA slope was -0.133 (range [-0.221, -0.027]) logMAR/mph pre-op, -0.149 ([-0.336, -0.065]) post-op in placebo mode, and -0.106 (range [-0.229, -0.043]) post-op in treatment mode.
Conclusions: Motion-modulated stimulation delivered by a unilateral vestibular implant improved posture, gait, DVA, and impact of cognitive load while walking.
Support: NIDCD U01DC019364, NIA R01AG076701
Targeted ionic direct current modulation of the macaque vestibular system
Evan O. Vesper1, Katherine N. Mueller2, Celia Fernandez Brillet1, Brian J. Morris1, W. Mitchel Thomas2, Charles C. Della Santina2, Gene Y. Fridman2
1Johns Hopkins University, Department of Biomedical Engineering, USA
2Johns Hopkins School of Medicine, Department of Otolaryngology - Head and Neck Surgery, USA
Purpose: We previously demonstrated delivery of targeted galvanic vestibular stimulation to rodent semicircular canals using ionic direct current (iDC). Adaptation to a cathodic baseline improved the dynamic range of the electrically evoked vestibulo-ocular reflex (eeVOR). Here we continue this work in a non-human primate (NHP) in a step toward clinical translation.
Methods: We developed an implant to deliver iDC to a rhesus macaque through microcatheters containing ionically conductive artificial perilymph gel. We targeted the horizontal canal with a return in the common crus. In the initial 3 post-operative months, the animal was regularly exposed to cathodic iDC baselines before current-controlled trapezoidal steps (50ms ramp, 150ms plateau) were delivered up to a ±400uA modulation amplitude. The 3D eeVOR was measured in darkness using scleral coils.
Results: We consistently measured eeVOR responses approximately aligned with the horizontal canal axis and the implant continues to function. A maximal excitatory eeVOR slow phase response of 610±100°/s (mean±SD) and inhibitory response of 80±50°/s were elicited without signs of facial nerve activation, although response magnitude has varied between days. Adaptation to a 100uA cathodic baseline increased the inhibitory response range to 2.8 times the range with no baseline, while the excitatory range remained constant to within 1%.
Conclusions: We demonstrated a method to stimulate the rhesus macaque vestibular system with targeted iDC. Further, adaptation to an excitatory baseline increased the total dynamic range of responses, consistent with previous work in rodents. These findings are promising for exploring chronic iDC stimulation in NHPs. Supported by: NIH/NIDCD R01DC018300, NIH 2T32EB003383.
The Vestibular Implant: Results of the second generation device
Raymond Van De Berg1, Nils Guinand2, Bernd Vermorken1, Stan van Boxel1, Benjamin Volpe1, Marieke ten Hoor1, Michaela de Kock1, Elke Loos3, Joost Stultiens1, Helen Yuan1, Elke Devocht1, Angelica Perez-Fornos2
1Maastricht University Medical Center, Department of Otorhinolaryngology and Head & Neck Surgery, The Netherlands
2Geneva University Hospital, Department of Otorhinolaryngology, Switzerland
3Leuven University Hospital, Department of Otorhinolaryngology, Belgium
Purpose: Patients with bilateral vestibulopathy suffer from a variety of complaints, such as oscillopsia, imbalance and cognitive complaints. Individually, this leads to a decreased quality of life and on a socio-economic level, the burden is high. The vestibular implant was designed to restore the vestibular deficit by providing motion information through implanted electrodes. It was previously demonstrated that this neuroprosthesis is feasible, as it can (partially) restore the reflexes such as the vestibulo-ocular reflex and vestibulo-collic reflex, as well as functional improvements on dynamic visual acuity, posture, gait and quality of life.
Methods: Nine patients with bilateral vestibulopathy were implanted with the second generation vestibulo-cochlear implant using peroperative imaging techniques. Vestibular reflexes, perceptual responses and functional outcome measures were tested.
Results: In the patients receiving the second generation vestibulo-cochlear implant, all electrodes were surgically placed close to the ampullary nerve. It was possible to electrically elicit a vestibulo-ocular reflex in all but one patient. Obtained eye velocities were significantly higher with this second generation device. Different types of perception were evoked in all patients, and functional tests such as dynamic visual acuity and vHIT showed improvement. It was demonstrated that vestibulo-cochlear implant fitting can significantly change Video Head Impulse Test results.
Conclusions: The latest vestibulocochlear implant can improve vestibular reflexes, vestibular perception, as well as functional tests. This shows its feasibility as a clinical useful device in the near future.
Tracing vestibular processing from end-organ to cortex: a study combining vestibular implant stimulation and EEG
Stan van Boxel1, Marcus Janssen2, Erik Gommer2, Bernd Vermorken1, Benjamin Volpe1, Joost Stultiens1, Marc van Hoof1, Nils Guinand3, Angélica Pérez Fornos3, Elke Devocht1, Raymond van de Berg1
1Maastricht University Medical Center, Department of Otorhinolaryngology and Head and Neck Surgery, Maastricht, the Netherlands
2Maastricht University Medical Center, Department of Clinical Neurophysiology, Maastricht, the Netherlands
3Geneva University Hospitals, Service of Otorhinolaryngology and Head and Neck Surgery, Geneva, Switzerland
Purpose: Elucidating the processing of information coming from the vestibular end-organ remains challenging. This induces the need for novel measurement strategies. In this study we tested the feasibility of a novel setup using a combination of vestibular implant stimulation and electrophysiological measurements. This setup enables highly controllable stimulation, combined with precise timing and localization of the response. Subsequently, this novel method was used to trace vestibular evoked potentials up to the cortex. At last, potential applications in vestibular implant related research were explored.
Methods: Two subjects were tested. A vestibular implant targeting the ampullary nerves was used to evoke vestibular potentials. The recording of short latency potentials was performed using one channel EEG, and a 128 channel EEG was used to record middle and long latency potentials. Responses were characterized in terms of latency, shape, location and its correlation with the stimulus. Response thresholds were compared with thresholds of perception and eye responses, as well as compared amongst subjects and target nerves.
Results: The measurement setup appeared feasible and resulted in reproducible responses. A short latency response was identified, proposed here as the vestibular brainstem response. Analysis of middle and long latency responses resulted in defined and localized independent components. The responses were correlated with the stimulus intensity. Response thresholds corresponded with perception and eye response thresholds.
Conclusions: The setup showed feasible, providing a unique novel method to study vestibular processing. Reproducible responses were characterized, and identified brain regions involved in vestibular processing. The method provides new opportunities for vestibular implant related research.
Update on Targeted Ionic Direct Current Vestibular Prosthesis at Johns Hopkins University
Gene Fridman1, Charles Della Santina1, Soroush Sadeghi1, Elisabeth Glowatzki1, Kathleen Cullen2, Katherine Mueller1, Evan Vesper1, Celia Fernandez Brillet2, Grace Foxworthy2, Yangsheng Xu1, William Thomas1, Dyllan Zhou1
1Johns Hopkins University, Otolaryngology, USA
2Johns Hopkins University, Biomedical Engineering, USA
Purpose: We have previously shown in chinchillas that delivering targeted galvanic vestibular stimulation in form of ionic direct current (iDC) to the individual canals could dramatically improve the dynamic range of the vestibular prosthesis. This work is ongoing with multiple PIs at JHU toward translation to human implants, and we have individual abstracts currently submitted. This is a summary of these efforts.
Methods: While all studies are proceeding in parallel, we have made considerable advances toward (1) technical implant design, (2) longitudinal safety studies in chinchillas, (3) first implant in monkeys, (4) computational models of neural responses, and (5) in-vitro and in-vivo neural recordings.
Results: (1) We have a new reliable design for an implant that can deliver 3 independent channels of iDC stimulation to each of the three canals, with one-channel prototype able to deliver arbitrary iDC stimuli up to ± 100uA. (2) Continual effective two-week iDC stimulation in the canals in a chinchilla suggest longitudinal safety. (3) Our first implant in a monkey has been effective for 3 months so far with the maximally evoked VOR responses between -100dps and +250dps consistent with the stimulated canal orientation. (4) Computational work created multiple testable hypotheses implicating strong hair cell effects driving the higher frequency iDC response patterns. (5) Electrophysiology experiments are ongoing to test computational model predictions.
Conclusions: We believe that iDC stimulation continues to show promise to improve vestibular prosthetic outcomes by increasing the dynamic range evoked sensation.
Support: NIH R01DC018300
Vestibular Implant Electrode Stability over time
Elke Loos1, Benjamin Volpe2, Bernd Vermorken2, Stan Van Boxel2, Elke Devocht2, Alinda Postma3, Nils Guinand4, Angelica Perez-Fornos4, Christian Desloovere5, Nicolas Verhaert5, Raymond van de Berg2
1Department of Otorhinolaryngology-Head and Neck Surgery, University Hospitals Leuven, Leuven, Belgium AND Department of Otorhinolaryngology-Head and Neck Surgery, School for Mental Health and Neuroscience (MHeNS), Faculty of Health Medicine and Life Sciences, Maastricht University Medical Center, Maastricht, The Netherlands
2Department of Otorhinolaryngology-Head and Neck Surgery, School for Mental Health and Neuroscience (MHeNS), Faculty of Health Medicine and Life Sciences, Maastricht University Medical Center, Maast
3Department of Radiology and Nuclear Medicine, School for Mental Health and Neuroscience (MHeNS), Faculty of Health Medicine and Life Sciences, Maastricht University Medical Center, Maastricht, The
4Department of Otorhinolaryngology-Head and Neck Surgery, Department of Clinical Neurosciences, Geneva University Hospitals,Geneva, Switzerland
5Department of Otorhinolaryngology-Head and Neck Surgery, University Hospitals Leuven, Leuven, Belgium
Purpose: The vestibulocochlear implant (VCI) is a new prosthesis, developed to artificially restore balance. The electrode position is thought to be important for optimal neural activation and efficient vestibular stimulation. In cochlear implants, migration of the electrode leads after surgery is not uncommon. As VCIs are relatively new, the migration of vestibular electrodes has not been studied before. The objective of this study was to evaluate the stability of the VCI electrode position over time and report on different fixation strategies.
Methods: Six patients implanted with a VCI at the Maastricht University Medical Center were prospectively followed over time. Different fixation strategies were used. When possible, the fenestrations of the semicircular canals were kept very small in order to stabilize the electrode lead. As an additional safety measure, the electrodes were fixed with hydroxyapatite bone cement or glass Ionomer luting cement.A CT of the temporal bone was performed intraoperatively, after approximately one week and after one year. All scans were analyzed for electrode migration using 3D slicer software.
Results: 22% of the electrodes showed a slight migration of more than 0.5mm between the intraoperative scan and the first postoperative scan. The mean migration distance of those electrodes was 0.54mm. None of the electrodes migrated out of the ampulla of the semicircular canals. Additionally, none of the electrodes migrated between the first postoperative scan and the one-year follow-up scan.
Conclusions: The newest fixation technique using small fenestrations when possible and glass Ionomer luting cement to fix the electrode leads seems to safely fixate VCI electrodes, providing a stable vestibular stimulation.
27. Others
Assessing the efficacy of acute vertigo training for emergency clinicians: a qualitative study
Nehzat Koohi1, Angus Ramsay2, Robert Simister3, Kevin Munro4, David Werring5, Diego Kaski1
1Department of Clinical and Movement Neurosciences, Queen Square Institute of Neurology, University College London, London, UK
2Department of Applied Health Research, University College London, London, UK
3Comprehensive Stroke Service, National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
4Manchester Centre for Audiology and Deafness, School of Health Sciences, University of Manchester, Manchester, UK
5Stroke Research Centre, Department of Brain Repair and Rehabilitation, Queen Square Institute of Neurology, University College London, London, UK
Purpose: To evaluate the impact of formal training on emergency clinicians' application of HINTS-plus, STANDING, and TiTrATE algorithms for diagnosing the causes of acute vertigo, emphasising not just on the acquisition of skills but also the implementation science behind adopting these techniques in emergency settings.
Methods: Training involved self-paced e-learning and practical sessions. Memory aids facilitated knowledge retention and application. Surveys and interviews assessed clinicians perceived confidence, algorithms usage, clinical approach alterations, and barriers to practice implementation.
Results: Following training, clinicians reported increased confidence, particularly in performing the HINTS-plus and positional manoeuvres, with most applying these techniques frequently. Although improvements in clinical approaches to vertigo were observed, with many clinicians experiencing some improvement in their clinical judgment, the integration of training into routine practice and distinguishing the causes of vertigo remained challenging. Participants identified practical demonstrations and interactive case studies as the most beneficial aspects of the training, while noting the lack of time and practice opportunities as significant barriers. The need for refresher sessions and on-the-job mentorship was highlighted to overcome these barriers. Memory aids effectively improved algorithm uptake.
Conclusions: The training program improved emergency clinicians' confidence and capability in diagnosing the causes of acute vertigo. Future training improvements should include the use of interactive learning technologies and continuous support. We recommend assessing the sustained impact of the training over a longer period and in diverse clinical settings to ensure successful long-term adoption of these diagnostic techniques into standard emergency protocols and, ultimately, to improve patient outcomes.
Development and validation of XGBoost model as a classification tool for diagnosing of peripheral vertigo
Xiaowu Tang1, Yuexin Cai1
1Department of Otolaryngology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University
Purpose: To develop a machine learning model for classifying different types of peripheral vertigo disease based on electronic medical records.
Methods: Study Design: Retrospective observational study.
Setting: Tertiary referral center.
Patients: Patients diagnosed with peripheral vertigo (PV) at one tertiary referral center from 2020 to 2021.
Intervention(s): Disease diagnosis was labeled by otolaryngologists. Machine learning methods were used to establish an algorithm for classifying diseases that cause vertigo.
Main Outcome Measure(s): Sensitivity, precision, accuracy, F1-score and area under the curve (AUC) of the machine learning algorithm compared to the original data .
Results: In Task 1, the XGBoost model classified benign paroxysmal positional vertigo (BPPV) and non-BPPV with an accuracy of 88.4% and AUC of 0.96, better than the other three algorithms logistic regression (LR), random forest (RF), and support vector machines (SVM), which had accuracies of 84.2%, 88.4%, 83.0%, and AUC of 0.94, 0.91 and 0.93, respectively. Application of the XGBoost model to patient symptoms achieved a better performance than clinician examination both in accuracy (79.9% vs 70.5%) and AUC (0.88 vs 0.86). In Task 2, the XGBoost model performed excellently in differentiating Menière's disease (MD), Sudden sensorineural hearing loss with vertigo (SSNHLV), and vestibular migraine (VM) with accuracies of 87.7%, 100%, and 87.7% respectively. Application to patient symptoms yielded a better performance than clinician examination in accuracy (84.9% vs 64.1% for MD, 84.9% vs 72.6% for VM, and 100% vs 85.9% for SSNHLV).
Conclusions: This study successfully developed diagnostic models for peripheral vertigo diseases using XGBoost. Its clinical application could provide great patient benefit in the differential diagnosis of vertigo diseases.
Diagnostic disparities in acute vertigo - emergency settings versus specialist vertigo clinics
Nehzat Koohi1, Maria Francisca Rocha2, Benjamin Sacks2, Alexander Heatley3, Diego Kaski1
1Department of Clinical and Movement Neurosciences, Queen Square Institute of Neurology, University College London, London, UK
2University College London Hospitals NHS Foundation Trust, London, UK
3University College London
Purpose: To evaluate the diagnostic discrepancies between emergency clinicians and neuro-otology specialists in patients presenting with acute vertigo and to propose methods to improve diagnostic accuracy.
Methods: This prospective cohort study reviewed 70 cases of acute vertigo, dizziness, or unsteadiness over one year. We calculated the rate of diagnostic accuracy by comparing the use of the HINTS-plus examination and STANDING algorithm in the emergency settings with neuro-otological evaluations at a tertiary centre.
Results: Initial diagnoses in the emergency setting matched those made by neuro-otology in only 23% of cases. Common bedside vertigo assessments were underutilised in the emergency settings: Dix-Hallpike and Roll test manoeuvres (13%), nystagmus testing (68%), head impulse testing (28%), skew deviation test (22%), and bedside hearing assessments (10%). Misdiagnoses in emergency settings led to delayed treatment and increased healthcare costs.
Conclusions: The study highlights significant diagnostic challenges in emergency settings. There is a critical need for specialised training for emergency clinicians to effectively utilise acute vertigo algorithms. Such training has the potential to reduce the rate of misdiagnoses and improve clinical outcomes for patients presenting with acute vertigo syndromes.
Does the absence of speech development predict functional balance in older children
Sphilile Mbhele1, Christine Rogers1, Peter Rea2, Qadeer Arshad2, Yougan Saman3
1University of Cape Town, Department of Audiology, South Africa
2University of Leicester, United Kingdom
3Imperial College London, Department of Brain Sciences, United Kingdom
Purpose: Previous research suggests a link between spoken language and motor skills in hearing and hearing-impaired subjects, with the suggestion that spoken-language and perceptual motor skills share underlying cortical processing resources. Hearing impaired children are more likely to have vestibular deficits, however, studies have failed to show a relationship between the degree of vestibular loss and functional balance. The question emerges as to whether children with hearing impairment who do not develop language have enduring balance dysfunction and whether the poor acquisition of spoken language is a predictor for poor outcomes. In this study we assess functional balance in hearing impaired older children to determine if the inability to develop spoken language correlates with functional balance.
Methods: The Pediatric Vestibular Symptom Questionnaire (PVSQ) and the Dizziness Handicap Inventory for Children (DHI-CA) are tools to identify vestibular symptoms and the impact of functional balance in children. We translated and validated these tools into Sign-Language suitable for children between the ages of 9 to 17 years. The PVSQ and DHI-CA scores were compared with results from the EQ-5D-Y proxy version questionnaire, modified Clinical Test of Sensory Interaction for Balance (mCTSIB), Mini- Balance Evaluation Systems Test (Mini-BESTest) and the Leiter International Performance Scale 3rd Edition. Our target group was deaf children with poor language acquisition who predominantly used Sign Language to communicate.
Results: 120 children were recruited. Children with deafness and poor language acquisition presented with significantly poorer balance function compared with speaking and hearing peers. The majority of the children with prelingual deafness showed difficulty with the mCTSIB, and attained high scores on the PVSQ and DHI-CA. These findings correlated with the EQ-5D-Y proxy version questionnaire, where parents raised concerns with QOL.
Conclusions: Our preliminary findings indicate that auditory deprivation and limited development of spoken language are strong predictors of balance function outcomes in older children.
Does the vestibular system affect time perception differently in different modalities?
Laurence Harris1, Fatemeh Ghasemi1
1York University, Centre for Vision Research, Toronto, Canada
Purpose: The perception of time is altered in microgravity (Navarro Morales et al. Microgravity 9: 2023) but in such a complex environment it is hard to identify this as specifically vestibular-mediated. Here, we manipulated the reliability of the vestibular cue by varying posture and by applying disruptive galvanic vestibular stimulation (dGVS) while measuring perceived time duration.
Methods: Participants (n=30 for each exp) judged whether a stimulus was longer or shorter than their personal estimate of 1s while lying and standing. In exp 1, participants judged the duration of an LED that was attached to stem protruding from a helmet and viewed at 50cm (so that it was at the same location as posture varied). In exp 2, they judged the duration of sounds (1,000hz) played through headphones. In exp 3, they judged the duration of a tactile vibration (200hz) delivered through tactors mounted on the backs of both hands. In exp 4, they judged visual duration with and without dGVS.
Results: There was no effect of posture on the estimation of 1s for auditory (771ms ± 69ms) or tactile stimuli (1,062ms ± 61ms). However, the perceived duration of 1s for the visual LED was 7% longer when lying (1,132ms ± 112ms) compared to when standing (1,068ms ± 104ms) (diff 64.6ms, p=0.005). Pilot data also suggest an increase under dGVS.
Conclusions: Interestingly, the perception of 1s varied depending which modality was being judged. But only visual judgements were affected by posture suggesting specifically visual time perception may be influenced by the vestibular system.
Evaluating the Accuracy and Completeness of AI Responses Against Established Otology Guidelines
Brian McKinnon1, Kassandra Corona1, Nicholas Rossi2, Yuki Yoshiyasu1, Dayton Young1
1University of Texas Medical Branch, Otolaryngology, United States
2University of Texas Medical Branch, Otolaryngology, UniteUniversity of Texas Medical Branch, Otolaryngology, United Statesd States
Purpose: The incorporation of artificial intelligence (AI), especially large language models (LLMs) like Generative Pretrained Transformer 4 (GPT-4), into medical practice is a burgeoning field of interest. This research evaluates the applicability of GPT-4 in otology by analyzing its responses to queries based on otologic clinical practice guidelines.
Methods: Key guidelines from otology were selected, and corresponding questions were formulated to examine GPT-4's interpretation and response accuracy. Two independent reviewers assessed the AI-generated answers for accuracy and completeness, using a structured Likert scale. A re-evaluation was conducted to evaluate the reproducibility of results.
Results: The analysis showed a high accuracy level (mean score: 4.75 out of 5) and completeness (mean score: 2.88 out of 3) in GPT-4's responses. The inter-rater agreement, as indicated by Cohen’s kappa, was substantial. GPT-4 consistently advised on individualized treatment plans and professional consultation, particularly for guidelines with weaker evidence, demonstrating its cautious approach in handling medical information.
Conclusions: GPT-4 exhibits promising potential as an auxiliary tool in otology, providing accurate and comprehensive information. However, its role should be viewed as supplementary, with emphasis on continual updates and careful monitoring to align with evolving medical knowledge. Future studies are recommended to further explore the depth of AI application in diverse clinical scenarios and its real-time impact on clinical outcomes.
Myriad Presentations of Vestibular Paroxysmia
Sandeep Kumar
1
1Bharti ENT &Vertigo Clinic, Ludhiana, Punjab, India
Purpose: To analyze various common & uncommon presentations in patients of vertigo responsive to carbamazepine and to study the relation of MRI findings with clinical presentation.
Methods: Retrospective analysis of data of 140 patients of vertigo, aged 10 to 80 years who presented to us, between 2018 to 2023 with varied presentation.
A thorough analysis of - History regarding complaints of vertigo, Imbalance, or Jerks and associated problems like Tinnitus, Hearing Impairment, etc. VNG examination including various oculomotor and Positional diagnostic maneuvers.
MRI findings especially regarding cross-compression of the 8thnerve by arterial or Venous loops.
Response of various symptoms to Carbamazepine or Lacosamide
Results: Cross-compression of the 8th nerve can present with a plethora of complaints ranging from unprovoked or positional spinning vertigo to imbalance, jerks, swaying, or ataxia. Multiple presentations in a single patient are very common. Various symptoms may be triggered by positional changes in the head, exercise, and physical activity. Duration of individual attacks again is highly variable ranging from quick spins lasting 1-2 seconds to as long as few hours. Tinnitus was present in 41% and hearing impairment in 37% of patients, on the side of cross compression. Both may precede vertigo by years. Several bizarre video-nystagmography findings like positional periodic alternating nystagmus, central positional nystagmus, changing patterns of nystagmus during different positions of a single positional maneuver, and positive hyperventilation tests etc. were frequently encountered in such patients. Positional vertigo in such patients was either recalcitrant to repositioning maneuvers or recurrent.
Conclusions: Patients of Vertigo having cross-compression of 8th nerve and responsive to Carbamazepine or Lacosamide, akin to vestibular paroxysmia, can have multiple presentations and not just that enumerated in Barany Society guidelines.
VP can mimic several other common causes of vertigo like Meniere disease or BPPV etc.
The clinical spectrum of this disease needs to be seriously reconsidered.
Neural correlates of vestibular adaptation in cosmonauts after long-duration spaceflight
Catho Schoenmaekers1, Steven Jillings1, Dmitrii Glukhikh2, Elena Tomilovskaya2, Ilya Rukavishnikov2, Peter Zu Eulenburg3, Floris Wuyts1
1Lab for Equilibrium Investigations and Aerospace, University of Antwerp, Antwerp, Belgium
2SSC-RF Institute for Biomedical Problems, Russian Academy of Sciences, Moscow, Russia
3Institute for Neuroradiology, Ludwig-Maximilians-University Munich, Munich, Germany
Purpose: Our prior research explored the otolith-mediated ocular counter-roll (OCR) and found pre- to post-flight eye torsion differences, influenced by flight experience. Similarly, resting-state functional magnetic resonance imaging (rsfMRI) analysis in a partially overlapping cosmonaut group showed post-spaceflight functional connectivity (FC) alterations. This study retrospectively examined if OCR changes correlate with FC changes in specific vestibular cortical regions post long-duration spaceflight mission.
Methods: Fourteen cosmonauts (mean age: 46.8±5.17 years; mission duration: 186.92±51 days) underwent pre- and post-spaceflight brain MRI scans (pre: 89±199 days; post: 9±3 days). The OCR was evaluated 154±109 days pre-launch and 3±1 days post-landing. Resting-state fMRI scans were acquired to evaluate the brain's functional architecture by examining spontaneous low-frequency fluctuations in the BOLD signal. FC was derived using a cortical vestibular atlas-based region-of-interest (ROI) approach. Vestibular function was measured using the OCR generated by off-axis centrifugation. Correlation between pre- to post-flight seed-based-connectivity (SBC) and OCR differences was examined (p<0.001 uncorrected, cluster-level p<0.05 corrected with FDR).
Results: Significant changes in FC were found between the vestibular seed region, OP2_PIVC r, and clusters involving the right and the left angular gyrus (38,72,52 and -52,-62,48). These cluster locations were confirmed using the AAL3 atlas toolbox of SPM12 alongside CONN's atlas. These alterations correlated with a simultaneous decrease in OCR (p(FDR)<0.020520, p(FDR)<0.038254), suggesting a link between greater OCR decrease and lower post-flight connectivity.
Conclusions: This underscores the angular gyrus' role in vestibular adaptation during spaceflight, aiding in cosmonauts' rapid adjustment to gravitational changes.
Oculomotor abnormality: a new biomarker of Wilson’s Disease
Minping Li1, Xue Xu1, Haiwei Huang1, Weiwei Qi1
1First Affiliated Hospital of Sun Yat-sen University, Department of Neurology, China
Purpose: This study aims to analyze ocular motor in Wilson’s disease (WD) and search for reliable indexes to distinguish between hepatic WD and neuropsychiatric WD, and to identify asymptomatic WD.
Methods: Forty patients with WD were compared in a retrospective study performed from July 2019 to October 2021. Eye movements, including fixation, smooth pursuit (SP), saccade, optokinetic nystagmus (OKN), prosaccade, and anti-saccade, were evaluated using video-nystagmography. MRI was performed using a 1.5T system and MRI lesions were recorded.
Results: Abnormalities of vertical saccade were the most salient finding as they appeared in 85% of WD patients. Hepatic WD patients had mostly abnormal accuracy, and all were hypermetria or hypometria, while prolonged latency, reduced speed, and accuracy were all found in WD patients with neuropsychiatric symptoms. SP, including horizontal and vertical SP, can be used to differentiate between neuropsychiatric and hepatic WD (horizontal: p <0.05; vertical: p <0.05). For patients with neuropsychiatric WD, the most common MRI lesions were globus pallidus (GP), followed by midbrain (Mi), putamen (Pu), and thalamus (Th).
Conclusions: We have demonstrated impairments of the ocular motor in WD patients and found vertical saccade was the most sensitive index and SP was a specific index for differentiating neuropsychiatric symptoms. The ocular motor may be a biomarker of WD in the future.
Sensorineural hearing loss negatively impacts cognition in older subjects with normal vestibular function
Hanne Gommeren1, Tinne Vandenbroeke2, Joyce Bosmans2, Griet Mertens1, Patrick Cras3, Sebastiaan Engelborghs4, Angelique Van Ombergen2, Annick Gilles1, Marc Lammers1, Vincent Van Rompaey1
1Department of Translational Neurosciences, Faculty of Medicine and Health Sciences, University of Antwerp - Department of Otorhinolaryngology and Head and Neck Surgery, Antwerp, Belgium
2Department of Translational Neurosciences, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
3Department of Neurology, Antwerp University Hospital and Institute Born-Bunge, University of Antwerp, Antwerp, Belgium
4Department of Neurology, University Hospital Brussel and Center for Neurosciences (C4N), Vrije Universiteit Brussel (VUB), Brussels, Belgium
Purpose: Worldwide around 400 million people suffer from hearing loss. There is increasing evidence that hearing loss is a modifiable risk factor for cognitive decline. However, several risk factors for cognition are common in hearing-impaired individuals, including vestibular dysfunction, anxiety and depression. We aim to explore the effect of hearing loss on cognitive functioning in older adults, considering the effects of vestibular function, anxiety, and depression on cognitive performance.
Methods: A cross-sectional study was performed with 42 subjects with moderate-to-severe sensorineural hearing loss (SNHL) and 42 matched normal-hearing controls. Matching was based on the following factors; sex, age, education level, level of anxiety and depression, and vestibular function. The test battery consisted of cognitive assessment (RBANS-H), hearing assessment (Pure Tone Average and speech-in-noise testing), and vestibular assessment (video Head Impulse Test (vHIT)). Depression and anxiety were evaluated using the Hospital Anxiety and Depression Scale (HADS) and Beck Depression Inventory (BDI) questionnaires.
Results: A significantly lower total cognitive (RBANS-H) score was observed in the group with SNHL compared to controls [100.93 (12.94) vs 108.88 (10.47), (p = 0.003)]. The difference among both groups was most pronounced in the subdomains Visuospatial/Constructional [92.90 (16.32) vs 103.12 (12.83), (p = 0.002)] and Attention [96.62 (12.52) vs 104.02 (11.81), (p = 0.007)]. The other subdomains Immediate Memory, Language, and Delayed Memory, did not differ significantly between the groups with SNHL and the normal-hearing controls.
Conclusions: In this cross-sectional study cognitive functioning was evaluated in a group with moderate-to-severe hearing loss and a matched control group based on sex, age, education level, vestibular function, anxiety and depression rates. The SNHL group performed significantly worse on the cognitive test, the differences were most pronounced for the cognitive subdomains of Attention and Visuospatial/constructional memory. Results from this study confirm that hearing loss negatively impacts cognitive functioning, even in older adults with normal vestibular function.
Spinning out of Control: Using Motion to Treat Pppd and a Hyperactive Vestibular System
Anna Mangano
1
1Baylor Scott and White Institute for Rehabilitation
Purpose: This course will focus on using motion to rehabilitate those persons with Persistent Postural Perceptual Dizziness. We will look through the physical therapy literature to determine the theory behind treating PPPD and motion sensitivity. Part of this course will examine the neural integrator and time constants and how we use these in physical therapy. We will discuss treatment ideas and strategies to treat and manage PPPD with motion and a transdisciplinary care team. The purpose of this lecture is to change the perception of the vestibular system and discuss pysical therapy treatment of PPPD with motion.
Methods: Case study examples with VNG and rotation chair testing will be used to demonstrate the current data for a hyperactive vestibular system.
Results: Results of physical therapy treatments including symptom modification and return to prior level of function will be discussed to focus on the imporance of phyiscal therapy in the management of PPPD.
Conclusions: At the conclusion of this lecture the listener will be able to understand how physical therapy can assist return those with PPPD to their prior level of function. Patients recover 80-90% of symptoms with motion based physical therapy and are able to return to their prior level of function.
Training future vestibular neurologists: Lessons from the two active programs in the United States (2016-2024)
Anand Bery1, Jennifer Alyono2, Daniel Gold3, Kristen Steenerson4
1The Johns Hopkins Hospital, Department of Neurology, Baltimore, MD, United States
2Department of Otolaryngology-Head & Neck Surgery, Stanford University, United States
3The Johns Hopkins Hospital, Departments of Neurology, Ophthalmology, Neurosurgery, Otolaryngology - Head & Neck Surgery, Emergency Medicine, and Medicine, Baltimore, MD, United States
4Departments of Otolaryngology—Head and Neck Surgery, Neurology and Neurological Sciences, Stanford University School of Medicine, United States
Purpose: Despite great clinical need, there are few formal training programs in vestibular neurology. To help efforts to expand access to vestibular education, we share our experiences (both successes and challenges) running the two active clinical vestibular neurology training programs in the United States (at Johns Hopkins University and at Stanford University, respectively).
Methods: We conducted semi-structured interviews with directors of both programs. Topics included how to initiate a program, curriculum design, recruitment, and didactic teaching. Fellows completed electronic surveys, with questions on motivations for entering vestibular neurology, as well as current clinical mix and practice setting. We sought feedback on the merits and drawbacks of their fellowship experience.
Results: All past and current fellows participated. Almost all cited an influential mentor as the primary motivation for entering vestibular neurology. Most fellows work in academic settings. More than half are primarily clinical. All spend more than 50% of their clinical time seeing patients with vestibular problems. All are involved in teaching at their local institutions. Exposure to a diversity of vestibular conditions and disciplines was a distinct strength of programs. Fellows would have appreciated greater graduated responsibility and more autonomy before independent practice.
Conclusions: Together, our programs have trained a majority of new vestibular neurologists in the United States in the past decade. Early mentorship proved pivotal to build interest among trainees. Broad clinical exposure and inter-disciplinary learning were most valuable to fellows, and these should be emphasized in future Vestibular Medicine curricula and fellowship program design.
Using Machine Learning Models to Identify Vertigo Syndromes in the Emergency Room
Chao Wang1, Miranda Morrison2, Kunal Chaturvedi3, Nicole Reid2, Graham Brooker4, Sally Rosengren2, Ali Braytee3, Gnana Bharathy3, Mukesh Prasad3, Miriam Welgampola2
1Institute of Clinical Neurosciences University of Sydney, Australia
2Institute of Clinical Neurosciences University of Sydney. Australia
3University of Technology Sydney Australia
4The Australian Centre for Field Robotics University of Sydney Australia
Purpose: To examine the utility of Machine Learning Models when seeking to identify the vertigo syndome in the Emergency Room.
Methods: Between Jan 2022 and Dec 2023, we recruited 685 vertigo patients presenting to the emergency room. All were administered a digital history which documented age, gender, symptom onset, quality, duration, frequency, triggering, associated aural symptoms, migraine-related symptoms and neurological symptoms, and cardiovascular risk factors. Gold standard diagnoses were provided by two neuro-otologists who had access to the history and examination findings. Thirty-seven features were used. We applied three machine learning algorithms (XG Boost, Cat Boost, Light GBM) to develop classification models.
Results: The expert diagnoses were Acute Vestibular Syndrome (AVS) in 292, Episodic Positional Vertigo (EPV) in 192, Episodic Spontaneous Vertigo (ESV) in 87 and unclear or multiple syndromes in 120. When using a “one Vs all” approach, the best performing models identified AVS, EPV and ESV with accuracies of 97, 95 and 92% and F1 Scores of 97, 91 and 67%. When using multi-label classification, accuracies of 83-84% and F1 Scores of 80-81% were reached.
Conclusions: Machine Learning Algorithms may prove useful when building diagnostic tools for non-expert physicians assessing vertigo in ER. Here we demonstrate how they help classify vertigo syndromes which is an important first step in the diagnosis of vestibular disorders
PPII:90 - ChatGPT vs. Google Gemini: Evaluating the Potential of Large Language Models for Vestibular Rehabilitation Education
Yael Arbel1, Yoav Gimmon2, Liora Shmueli1
1Bar-Ilan University, Department of Management, Israel
2Sheba Medical Center, Department of Otolaryngology-Head and Neck Surgery, Israel
Purpose: We aimed to evaluate the performance of two different publicly available large language models, ChatGPT and Google Gemini in response to multiple-choice questions related to vestibular rehabilitation.
Methods: The study was conducted among 30 physical therapists (PTs) professionals experienced with VR (vestibular rehabilitation) and 30 physical therapy students. They were asked to complete a Vestibular Knowledge Test (VKT) consisting of 20 multiple-choice questions categorized into three groups: (1) Clinical Knowledge, (2) Basic Clinical Practice, and (3) Clinical Reasoning. ChatGPT and Gemini were asked with answering the same 20 VKT questions. Three expert board-certified otoneurologists evaluated independently the accuracy of each response provided by the model with the higher score. They used a 4-level scale ranging (from comprehensive to completely incorrect) to rate each response
Results: ChatGPT performed better than Google Gemini on the VKT (70% vs. 60% respectively). Both excelled in Clinical Knowledge (100%) but struggled in Clinical Reasoning (50% vs 25% respectively). In According to three otoneurologic experts, ChatGPT's accuracy was “comprehensive” for 9 of the 20 questions (45%), while 5 (25%) were “completely incorrect.” ChatGPT provided “comprehensive” responses in 50% of Clinical Knowledge and Basic Clinical Practice questions, but only 25% in Clinical Reasoning.
Conclusions: Caution is advised when using ChatGPT and Google Gemini due to their limited accuracy in clinical reasoning. While they provide accurate responses concerning Clinical Knowledge, their reliance on web information may lead to inconsistencies. ChatGPT was more accurate than Gemini. Healthcare professionals should carefully formulate questions and be aware of the potential influence of the online prevalence of information on ChatGPT's responses. Combining clinical expertise and guidelines with ChatGPT and Google Gemini can maximize benefits while mitigating limitations.
4. Benign Paroxysmal Position Vertigo
PPIII:01 - A novel BPPV training tangible head model with membranous labyrinth
HIDEO SHOJAKU1, Chiaki Suzuki2, Shigeyuki Murono3, Hayato Shirakawa4, Hideaki Ono5, Hidenori Ono4
1University of Toyama, Collaborative Research Laboratory of Medical Device Innovation
2Fukushima Medical University, Department of Otolaryngology, Date ENT clinic PaoPao
3Fukishima Medical University, Department of Otolaryngology
4Japan Medical Company
5Japan Medical Company, Keio University, Graduate School of Medicine
Purpose: The purpose was to clarify the usefulness of a newly created BPPV training tangible head model with membranous labyrinth (M-BPPV model) compared with that with osseous labyrinth (O-BPPV model) (BPPV training model, Japan Medical Company Inc., Tokyo, Japan).
Methods: In both M-BPPV and O-BPPV models, a head model is 1.5 times the actual size and has two bilateral mockups of semicircular canal (SCC). The SCCs are 10 times the actual size and contain 10 canalith particle in aqueous liquid. There is a lucent diaphragm between the ampulla and utricle, so the canalith can’t be moved from the ampulla to the utricle through the diaphragm. Each mockup of a SCC in the head model is located in the same position as in the human head. Epley maneuver for posterior SCC BPPV and Lempert maneuver for horizontal SCC BPPV were performed using both models. In each maneuver, 10 canalith particle was tried to be moved from the right SCC to the utricle, and the movement of the particle was observed in each head position.
Results: In the Epley maneuver, all particles were moved from the posterior SCC to the utricle in the siting upright position in both models. In the Lempert maneuver, all particles were moved from the horizontal SCC to the utricle in the head position toward the unaffected ear in the O-BPPV model, while those was moved in the head position of nose down in the M-BPPV model.
Conclusions: In the M-BPPV model, the movement of floating canalith was more accurately reproduced compared to that in the O-BPPV model in both maneuvers. So, it seemed that the M-model could be more helpful in understanding each maneuver.
PPIII:02 - A subtype of light cupula? Unique direction changing positional nystagmus
Yasuo Ogawa1, Taro Inagalki2
1Tokyo Medical University Hachioji Medical Center, Department of otolaryngology and head and neck surgery, Japan
2Tokyo Medical University , Department of otolaryngology and head and neck surgery, Japan
Purpose: Positional nystagmus of horizontal canal type is classified as direction-changing apogeotropic nystagmus and direction-changing geotropic nystagmus. There are two types of geotropic nystagmus, one is a transient type and the other is a persistent type. Transient type geotropic nystagmus is thought to be due to the canalolithiasis of the horizontal canal and persistent geotropic nystagmus is thought to be due to a light cupula of the horizontal canal. A characteristic feature of a light cupula patient is the presence of neutral point during the supine head roll test. At this point, nystagmus disappears and the direction of nystagmus reverses on either side. Some patients exhibit the neutral position exists near 90° either side in the supine head roll test. In the supine head roll test of these patients, horizontal nystagmus continues in the supine position, and it ceases and the nystagmus direction reversed to opposite when the head is turned to the right or left ear by about 90°. The mechanism of the unique DCPN is unclear.
Methods: We present a patient with the neutral position is about 90° either side in the supine head roll test and investigate the possible mechanism of the unique DCPN. We also present the clinical features of these patients with similar unique DCPN.
Results: Ten patients showed the direction changing nystagmus with the neutral position exists near 90°in the supine head roll test. The chief complaits of these patinents were positional nystagmus. The nystagmus and symptoms disappeared spontaneously within 1month in all patients. All cases had recurrence of positinal vertigo.
Conclusions: The cause of the unique DCPN seemed to be the subtype of light cupula, namely, due to the large deflection angle of the cupula in the horizontal canal.
PPIII:03 - Altered parietal operculum cortex 2 functional connectivity in BPPV patients with residual dizziness
Zhengwei Chen1, Liangqun Rong1, Lijie Xiao1, Haiyan Liu1, Xiu-e Wei1
1The second affiliated hospital of Xuzhou medical university, Department of neurology, China
Purpose: To investigate changes in functional connectivity (FC) focusing on parietal operculum cortex 2 (OP2) in benign paroxysmal positional vertigo (BPPV) patients with residual dizziness (RD) after successful canalith repositioning procedure (CRP).
Methods: High-resolution three-dimensional T1 and resting-state functional magnetic resonance imaging (fMRI) were performed on 55 healthy controls (HCs), 55 BPPV patients with RD, and 55 patients without RD after successful CRP. Seed-based (bilateral OP2) FC was calculated to investigate the changes in FC among the three groups. Additionally, we further explored the associations between abnormal FC and clinical symptoms.
Results: One-way analysis of covariance showed significant FC differences among the three groups. Post-hoc analysis showed that patients with RD exhibited decreased FC between left OP2 and regions of left angular gyrus (AG), thalamus, precuneus, middle frontal gyrus (MFG), and right cerebellum posterior lobe (CPL) in comparison with HCs. In addition, compared with patients without RD, patients with RD showed decreased FC between left OP2 and regions of left MFG, AG, middle temporal gyrus, and right CPL. Moreover, in patients with RD, the FC between left thalamus and OP2 was negatively correlated with duration of RD, and the FC between left AG and OP2 was negatively correlated with duration of BPPV.
Conclusions: BPPV patients with RD showed reduced FC between brain regions involved in vestibular processing and spatial cognition; These results suggested that BPPV patients with RD might have diminished central processing of vestibular information and impaired spatial cognition.
PPIII:04 - An Unusual Case of Directional Changing Benign Positional Vertigo
Yew-Meng Chan1, Khuzaimah Saini1, Joyce Tang1, Chun-Wai Yip1, Brenda Sim1, Stephanie Yeap1
1Singapore General Hospital
Purpose: 1. To highlight the need for prolonged video eye recording in the management of Horizontal Canal Benign Positional Postural Vertigo (BPPV) 2. Describe the pathogenesis and underlying etiology of this unusual presentation of a patient presenting with multiple directional changing nystagmus in a single roll position 3. Unique clinical features of a subset group of patients with horizontal canal BPPV described.
Methods: A patient with recurrent episodic vertigo resulting from BPPV was followed up for 4 years. Video eye recording of the patient was performed during an acute episode of acute vertigo. Review of similar cases of directional changing nystagmus of Horizontal Canal BPPV in a single roll position in the same institution.
Results: Positional eye recordings are presented in this poster. Other audiovestibular test results are also presented with Vitamin D level and MRI findings. The underlying past history of this patient with history of migraine is described. The benign course of this illness was managed successfully with positional maneuvers.
Conclusions: Directional changing positional nystagmus has been a concern for the Physician to exclude central vestibular cause. We present a case report of a patient with multiple directional changing nystagmus in a single roll position that was successfully managed with conservative management.
PPIII:06 - Caloric Response in Light Cupula BPPV
Seong Hoon Bae1, Sang Hyun Kwak2, Jeon Mi Lee3, Dae Bo Shim4, Sung Huhn Kim1
1Yonsei Univsersity College of Medicine
2Catholic University College of Medicine
3Inje University College of Medicine
4Hanyang University College of Medicine
Purpose: To suggest the pathophysiology of light cupula (LC) by analyzing the caloric responses and clinical course in the patients with the LC and other variants of lateral semicircular canal benign paroxysmal positional vertigo (LSCC BPPV).
Methods: A total of 101 patients diagnosed with light cupula (N=34, LC), heavy cupula (N =40, HC), and canalolithiasis (N=27, Canal) involving the LSCC were enrolled. Video head impulse test (vHIT) results of enrolled patients were normal. Caloric tests were conducted on the day of diagnosis and on follow-up visits after the disappearance of nystagmus. Difference of caloric test results and clinical course were compared among each type of LSCC BPPV and analyzed.
Results: Disease duration was significantly longer in LC patients (23 days) than those in HC (8 days) and Canal (9 days) patients (p<0.005). LC patients demonstrated the highest canal paresis (CP) value (vs. HC: p = 0.002 and vs. Canal: p < 0.001) and frequency of abnormal CP (61.8%) compared to HC (22.5%) and canalolithiasis (11.1%) groups. CP was predominantly ipsilateral (85.6%) in LC patients. Follow-up caloric tests showed decreased CP in 8 of 11 (72.7%) LC patients, 4 of them (36.4%) had normalized CP, after the disappearance of nystagmus.
Conclusions: In conclusion, the finding of clinical course, caloric test, and vHIT in the patients with different types of LSCC BPPV in this study can suggest that the pathophysiology of each type should be different. It is plausible that deflection of cupula by buoyancy in LC causes caloric weakness but intact vHIT.
PPIII:07 - Cerebellar ataxia presenting as a BPPV mimic
Heather Panic1, David Rastall2
1University of Florida, Department of Neurology, United States
2Johns Hopkins Hospital, Department of Neurology, United States
Purpose: Short-duration episodic vertigo related to rolling over in bed is typically diagnosed as BPPV but can also represent other disease processes. Here we present a case of ataxia which was misdiagnosed as BPPV for years.
Methods: Single case report.
Results: A 43-year old woman presented to the neurovestibular clinic with three years of episodic vertigo. She met most of the Barany criteria for BPPV, having 1) recurrent attacks of positional vertigo provoked by lying down or turning over in the supine position, 2) duration of attacks <1 minute, and 3) positional nystagmus provoked by the Dix-Hallpike maneuver with a latency of a few seconds or less. As a result, she carried a diagnosis of BPPV for years and had seen five providers with no resolution of her symptoms despite extensive attempts at canalith repositioning maneuvers. On exam, while nystagmus was elicited by multiple positional maneuvers the nystagmus did not follow a canal plane. Instead, there was worsening of downbeat nystagmus in lateral gaze without clear torsional component. During asymptomatic testing, central eye movement findings were seen including gaze-evoked nystagmus in lateral gaze with rebound nystagmus and a downbeating nystagmus induced by convergence and lateral gaze. She also had non-ocular signs of ataxia including an ataxic gait and dysmetria on finger-nose-finger testing. After intense therapy she had reduction of ataxia signs but no change in oculomotor signs.
Conclusions: Cases of cerebellar ataxia may initially present with all Barany criteria for BPPV except the characteristic patterns of eye movement, and therefore these patterns are essential to understand. We contrast here the ‘canal plane’ positional nystagmus seen in BPPV (in which torsional nystagmus should increase in ipsi-canal gaze and vertical nystagmus in contra-canal gaze) with central patterns. The poster will feature videos of both with clear explanations as a useful reminder of these eye movement details.
PPIII:08 - Comparison of perceptual pressure and vertigo status before and after treatment of benign paroxysmal positional vertigo
YANMEI FENG1, QIONG LUO1, YEMENG HE1, JIAMEI CHEN1, SHANKAI YIN1
1Shanghai Sixth People's Hospital, Otolaryngology, China
Purpose: To compare the changes of Vertigo status and perceived pressure in patients with Benign Paroxysmal Positional Vertigo (BPPV) before and after reduction treatment,and to analyze the influencing factors and correlation between vertigo disorder and perceived pressure in patients with BPPV.
Methods: Selected 50 patients diagnosed as primary BPPV from Shanghai Sixth People's Hospital from September 2022 to August 2023 as experimental groups,collected their clinical data, and used the Chinese Perceived Stress Scale (CPSS),and Dizziness Handicap Inventory (DHI),review the patients after one month of resetting treatment,and evaluate DHI and CPSS again; In the control group,the DHI and CPSS quantity tables are evaluated to analyze the influencing factors and correlations of the degree of dysfunction disorder and perception of BPPV patients.
Results: There were 50 BPPV patients in the experimental group,One week after reduction treatment,40 cases of BPPV were cured,7 cases were improved,3 cases were ineffective, and the effective rate was 94.0%. Reduction treatment could significantly improve the subjective vertigo symptoms and stress state of the patients;The comparison of DHI and CPSS scores before treatment in the experimental group showed that there was no significant correlation between the two groups.However,the perceived stress of patients with severe vertigo disorder was mainly severe,and the higher the DHI score was,the greater the perceived stress was.
Conclusions: Patients with BPPV had moderate vertigo disorder,and their perceived pressure was mainly severe. Reduction treatment could significantly improve the subjective vertigo symptoms and stress state of the patients,greater perceived stress in patients may be related to BPPV,DHI can quantify vertigo symptoms and evaluate the quality of life of BPPV patients,CPSS can evaluate the perceived stress status and health problems of BPPV patients before and after treatment,and the application of relevant scales is helpful for the prevention and evaluation of BPPV,and take corresponding intervention measures.
PPIII:09 - Diagnostics of Benign Paroxysmal Positional Vertigo: manual versus mechanical rotation chair diagnostics
Malene Hentze Hansen1, Dan Dupont Hougaard1, Herman Kingma1
1Balance & Dizziness Centre, Department of ENT and Audiology, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
Purpose: This study aimed to compare diagnostics with traditional manual Benign Paroxysmal Positional Vertigo (BPPV) with diagnostics using a mechanical rotation chair (MRC).
Methods: Open-label prospective randomized controlled clinical trial with a crossover design was undertaken at a tertiary outpatient clinic at Aalborg University Hospital, Denmark. Participants (n=215), adults with a typical BPPV case histories referred from general practitioners and ENT specialists, underwent both manual diagnostics and diagnostics with MRC. Positional testing with both diagnostic modalities was done with videonystagmography goggles in situ. The Bárány Society BPPV diagnostic criteria were used, and the order of test modality was randomized prior to enrolment.
Results: Preliminary analysis shows that MRC has a higher sensitivity for BPPV detection compared to manual diagnostics. When comparing manual diagnostics with MRC diagnostics (set as reference test), sensitivity, specificity, positive predictive value, and negative predictive value were 69.5%, 90.9%, 88.0%, and 75.8% respectively. Overall agreement between modalities was 80.5% (Cohen’s kappa 0.61), decreasing to 60.0% (Cohen’s kappa 0.23) with impaired cooperation during manual diagnostics. Both modalities detected an equal amount of posterior BPPV cases (p-value=0.51).
Conclusions: MRC demonstrates a higher sensitivity for BPPV detection compared to manual diagnostics, and even more in patients with impaired cooperation during manual diagnostics. Both modalities, however, had equal detection rates for monocanal posterior BPPV. Results emphasize that manual diagnostics is sufficient for diagnosing posterior BPPV, but that MRC diagnostics is superior in patients with an evident BPPV case history and a negative outcome with manual diagnostic or complex BPPV type.
PPIII:10 - Dizziness symptoms, balance confidence and vestibular function in older women reporting dizziness and unsteadiness
Ellen Lindell1, Lena Kollén2, Caterina Finizia2
1University of Gothenburg, Södra Älvsborgs hospital
2University of Gothenburg, Sahlgrenska University hospital
Purpose: The aim of this paper is to evaluate older women who report dizziness on a daily or weekly basis, but who do not seek medical care for their problems, for levels of PROMs related to dizziness, balance confidence, vestibular impairment, BPPV walking speed, TUG, balance confidence, depression and anxiety.
Methods: Patients coming for bone density measurements answered questions regarding occurrence of dizziness. Women reporting dizziness on a daily or weekly basis were considered eligible and invited for investigation at the Ear, Nose and Throat clinic at Södra Älvsborg Hospital, Sweden. Patients completed the Dizziness Handicap Inventory (DHI), Activities-specific Balance Confidence Scale (ABC-scale) and Hospital Anxiety and Depression Scale (HADS) and were investigated for benign paroxysmal positional vertigo with the video Head Impulse Test (vHIT), walking speed, and TUG test.
Results: Fifty-two female patients were enrolled. Associations were found between high levels of DHI and high distress due to dizziness, and low levels of balance confidence and reduced walking speed and TUG test time. Participants with higher DHI levels reported higher levels of both depression and anxiety. No associations were found between levels of DHI and results on vestibular tests.
Conclusions: Women reporting higher levels of distress due to dizziness had reduced walking speed and reported less balance confidence and higher levels of anxiety and depression. The findings support the theory that DHI captures aspects of overall self-rated wellbeing and function rather than structural vestibular deficits.
PPIII:11 - Functional improvements in Persons with Benign Paroxysmal Positional Vertigo and Vestibular Agnosia: A case series
Regan G. Harrell, PT, DPT, NCS1, Susan L. Whitney, DPT, PhD, NCS, ATC, FAPTA1
1The University of Pittsburgh, Department of Physical Therapy, USA
Purpose: This case series describes outcomes of three patients with Benign Paroxysmal Positional Vertigo (BPPV) who presented with vestibular agnosia. The BPPV diagnosis is driven by patient reported symptoms during positional testing. People with traumatic brain injuries (TBI) can have BPPV but not report any of the typical associated symptoms (vestibular agnosia). The purpose of this case series is to demonstrate that functional improvements can be made in those with BPPV and vestibular agnosia.
Methods: Three patients were seen in an inpatient rehabilitation unit with posterior canal BPPV with no symptoms, yet all had torsional upbeating nystagmus during Dix Hallpike testing.
Results: Patient 1 presented with a bilateral TBI with a daily Agitated Behavior Scale score of 41/56. After completing the canalith repositioning maneuver (CRM) her daily Agitated Behavior Scale decreased to 23/56. Patient 2 had multi-compartment hemorrhaging with an 11/30 on the Functional Gait Assessment (FGA) prior to positional testing. After repositioning (same treatment session) his FGA improved to 19/30. Patient 3 presented with a left subdural hematoma. His FGA prior to testing was 19/30 and immediately after the repositioning maneuver his FGA was 24/30. Both Patient 2 and 3 met the minimally clinically important difference for the FGA of four points in the same session.
Conclusions: BPPV, even when symptoms are not present, should be treated as functional outcomes can improve including a reduction in agitation and fall risk in persons with vestibular agnosia.
PPIII:12 - Head-Shaking Maneuver in Cupulolithiasis of the Posterior Canal Benign Paroxysmal Positional Vertigo
Eun Hye Oh1, Jae-Hwan Choi1, Seo Young Choi2, Hyun Ah Kim3, In soo Moon4, Hyun sung Kim5, Kwang-Dong Choi2
1Pusan National University Yangsan Hospital
2Pusan national university hospital
3Keimyung University Dongsan Hospital
4Daedong Hospital, Busan
5Gyungsang National University Changwon Hospital
Purpose: To determine the immediate and short-term therapeutic efficacy of head-shaking and mastoid oscillation maneuvers in PC-BPPV-cu.
Methods: This double-blind, randomized, controlled trial was conducted at 6 referral-based university hospitals in South Korea between November 2019 and April 2023. Of 179 patients (age ≥ 20 years) diagnosed with PC-BPPV-cu, 159 were enrolled after excluding 20 who declined to participate and had cervical spine problems, multicanal BPPV, or cognitive dysfunction. Patients were randomly assigned to the head-shaking, mastoid oscillation, or sham maneuver group. After a maximum of two trials of each maneuver, therapeutic response was assessed within 30 minutes and in the following day.
Results: The primary outcome was the short-term resolution rate of positional vertigo and nystagmus in the following day. The secondary outcome was the immediate efficacy of two trials of each maneuver within 30 minutes. 159 patients were randomized to the head-shaking (n=53, mean [SD] age, 64.0 [11.2] years, 33 [62%] women), mastoid oscillation (n=53, mean [SD] age, 66.5 [11.1] years, 41 [77%] women), and control group (n=53, mean [SD] age, 65.6 [9.2] years, 34 [64%] women). A total of 142 patients (89.3%) completed the assessment in the following day. In the intention-to-treat analysis, 20 of 53 patients (37.7%) in the head-shaking group, 14 of 53 patients (26.4%) in the mastoid oscillation group, and 7 of 53 patients (13.2%) in the control group showed the resolution of vertigo and nystagmus in the following day (P = .007; α = .05). For the secondary outcome (the immediate effectiveness of two trials of each maneuver within 30 minutes), no significant difference was detected (6 of 53 [11.3%] vs 4 of 53 [7.5%] vs 2 of 46 [3.7%]; P = .339; α = .05).
Conclusions: This trial showed short-term therapeutic efficacy of head-shaking maneuver for the treatment of PC-BPPV-cu.
PPIII:13 - Inertial Seated-Side Lying Test: A new positional nystagmus detection protocol
Diego Olmedo1, Cristofer Salazar1, Carolina Oliva1, Paul Délano1, Paula Altamirano2
1Hospital Clinico Universidad de Chile, Otorhinolaryngology, Chile
2Clinica INDISA, Otorhinolaryngology, Chile.
Purpose: Describe and explain physical-anatomical basis, the application and benefits of the proposed new protocol of the positional nystagmus detection “Inertial Seated-Side Lying test”.
Methods: Describe the evaluation proposal that consists of: Side-Lying test, (already published) for vertical SCCs; and Half Gufoni maneuver, (proposed by the authors) for horizontal SCCs. The study is performed with videonystagmography (VNG) in two patients with BPPV.
Results: In the subjects with BPPV evaluated with the proposed detection maneuver protocol, the expected positional nystagmus response was obtained, depending on the expressed variant and affected SCC. The VNG records and videos are presented, evidencing a positive BPPV and validating the usefulness of the maneuver.
Conclusions: The positional nystagmus evaluation maneuvers currently used are highly sensitive for BPPV; however, in patients with cervical limitations and movement restrictions, these maneuvers could be difficult and the canal stimulation is not always the most correct. The proposed protocol is an alternative to these situations, which in addition to reducing time, can reduce symptoms during the evaluation, due to its inertia biomechanical basis.
This protocol does not have any sensibility studies, but it is in the evaluation process.
PPIII:14 - Isolated Superior Semicircular Canal Paresis Following Stapes Surgery - A BPPV Spectrum Complication
Miguel Campos Lopes1, Vera Miranda1, Luciana Rodrigues1, Alexandra Correia1, Paulo Gonçalves1
1Department of Otorhinolaryngology, Unidade Local de Saúde de Entre o Douro e Vouga, Santa Maria da Feira, Portugal
Purpose: Stapes surgery is a commonly performed procedure in otosclerosis, and one of its major complications is postoperative vertigo. Since the introduction of the video head impulse test (vHIT), topographical diagnosis of vestibular pathology improved significantly.
We present a case of isolated superior semicircular canal paresis following stapes surgery, discussing its probable etiology in relationship with benign paroxysmal positional vertigo (BPPV).
Methods: Case Report.
Results: A 37-year-old man underwent stapes surgery with associated canalplasty, without any intra-operative incidents. Upon awakening from anesthesia, he experienced intense dizziness, and a spontaneous nystagmus was noted. vHIT was performed, which revealed an isolated superior semicircular canal paresis, ipsilateral to the operated ear (gain 0,46 with disperse corrective saccades). cVEMP testing revealed normal amplitude and symmetry.
After resolution of the acute vertigo, symptoms of gaze stabilization on the affected plane as well as positional vertigo persisted. Diagnostic maneuvers were initially unremarkable, and a diagnosis of complete canalith jam was suspected. The patient was treated with multiple Semont Plus maneuvers with mastoid vibration, with complete resolution of complaints. Subsequent vHIT testing revealed improved canal gain and saccade pattern.
Conclusions: We present a unique complication of stapes surgery, not previously described in the literature, discussing its diagnosis and therapeutic approach. vHIT topographical diagnosis is paramount in the management of vestibular complications of middle ear surgery and has the potential to greatly improve postoperative vertigo care in stapes surgery.
PPIII:15 - MASSETER VESTIBULAR EVOKED MYOGENIC POTENTIALS IN BENIGN PAROXYSMAL POSITIONAL VERTIGO INDIVIDUALS
Kalaiyarasan Ravichandran1, Sujeet Kumar Sinha2
1Junior Research Fellow, Department of Audiology, All India Institute of Speech and Hearing, Mysuru, Karnataka, India
2Associate Professor, Department of Audiology, All India Institute of Speech and Hearing, Mysuru, Karnataka, India
Purpose: Masseter Vestibular Evoked Myogenic Potential (mVEMP) is a novel test that assesses the functional integrity of the vestibulomasseteric reflex pathway. mVEMP is helpful in the diagnosis of the brainstem lesion in patients with multiple sclerosis, Parkinson's disease, and idiopathic REM sleep disorders. This study aimed to characterize mVEMP in individuals with BPPV.
Methods: Group I included twenty individuals (8 males & twelve females) with BPPV (11 right posterior canals, two right lateral canals, six left posterior canals, and one left lateral canal). Group II included healthy controls (10 males, ten females). A 500Hz tone-burst (2-0-2 cycles) mVEMP was recorded for ipsilateral, contralateral, and binaural stimulation modes. The repetition rate was 5.1/s at stimulus was presented at an intensity level of 125dBpeSPL. The reference electrode was placed at the zygomatic arch, the active electrode at the lower third of the masseter belly tendon, and the ground at the lower forehead.
Results: mVEMP was present for all the participants in both groups. Mann-Whitney U test showed a significant difference (p<0.05) for latency (p11, n21) and rectified amplitude (p11-n21) parameters between BPPV individuals and healthy controls for ipsilateral p11-n21 (Z=3.74, p=0.00), contralateral p11 (Z=2.49, p=0.01), p11-n21 (Z=4.63, p=0.00); binaural p11 (Z=2.52, p=0.01), n21 (Z=2.11, p=0.03); p11-n21 (Z=3.24, p=0.00).
Conclusions: This study revealed a significant difference between BPPV individuals and healthy controls for latency (p11,n21) and amplitude parameters of mVEMP for ipsilateral, contralateral and binaural stimulation modes. The major limitation of the study was the small sample size used in this study.
PPIII:16 - New liberatory maneuver for treatment of anterior canal benign paroxysmal positional vertigo
Prateek Porwal1, Srinivas Dorasala2
1ENT and Vertigo Specialist, PRIME ENT Center, UP, INDIA
2Ear, Nose and Throat (ENT) Department, Jawaharlal Nehru Medical College (JNMC), Belagavi, Karnataka, INDIA
Purpose: This article describes the treatment options for anterior semicircular canal benign paroxysmal positional vertigo. Anterior canal benign paroxysmal positional vertigo is very rare cause of benign paroxysmal positional vertigo and there are very limited therapeutic options
Methods: Forty-eight patients of anterior canal benign paroxysmal positional vertigo showing down beating nystagmus on Dix Hallpike and supine head hanging test were studied from 2018 to 2023.
Results: They were treated with a new maneuver with following steps: Step 1 – Bending forward from kneel down position so that the forehead is touching the surface, Step 2 – Flex the neck by 20 degrees more, Step 3 – Sit Up very fast with the head extended by 20 degrees and Step 4 –Lastly bend the head forwards by 20 degrees while sitting in the same position for 1 minute.
Conclusions: All our cases showed no nystagmus on repeating the positional tests. This new liberatory maneuver can be used for treating anterior canal bppv.
PPIII:17 - Otologic disorders in patients with benign paroxysmal positional vertigo (BPPV) : A systematic review
Mustafa Karabulut1, Sevgi Kutlu2, Ali Melliti1, Wolfgang Viechtbauer3, Alfarghal Mohamad4, Osman Nuri Özgirgin5, Anita Bhandari6, Herman Kingma7, Raymond van de Berg1
1Department of Otorhinolaryngology and Head and Neck Surgery, School for Mental Health and Neuroscience, Maastricht University Medical Center, Maastricht, Netherlands
2Department of Audiology, Ankara University Faculty of Health Sciences, Ankara, Türkiye
3Department of Psychiatry and Neuropsychology, Maastricht University, Maastricht, Netherlands
4Department of Ear Nose Throat, King Abdul Aziz Medical City, Jeddah, Saudi Arabia
5Department of Otolaryngology-Head and Neck Surgery, Bayındır Hospital, Ankara, Türkiye
6NeuroEquilibrium Diagnostic Systems Pvt. Ltd., Jaipur, India
7Department of Ear Nose Throat, Aalborg University Hospital, Aalborg, Denmark
Purpose: To systematically investigate the co-occurrence of otological disorders in patients with benign paroxysmal positional vertigo (BPPV).
Methods: A systematic search was performed in Pubmed and Web of Science to investigate the co-occurrence of otological disorders in patients with BPPV. All original studies in English, from full-text clinical trials to case reports, involving participants ≥18 years old, were included. Two types of articles were identified: 1) studies about BPPV patients in which co-occurring otological disorders were reported; 2) studies about otological disorders in which co-occurring BPPV was reported. The frequency of otological disorders in BPPV patients in both types of articles was analyzed.
Results: A total of 2385 studies were retrieved of which 67 articles were included in the analysis. Twenty-three out of 67 articles involved studies about BPPV patients with co-occurring otological disorders. In these studies, 9% of patients had otological disorders (1234/13639). Forty-four out of 67 articles involved studies about otological disorders in which co-occurring BPPV was reported. In these studies, 11.5% of patients were diagnosed with BPPV (1088/9421). Fourteen co-occurring otological disorders were found, of which the most frequently reported involved: Menière’s disease (11%), acute unilateral vestibulopathy/vestibular neuritis (10.3%), sudden sensorineural hearing loss (6.2%), labyrinthitis (5.1%) and post-surgical otologic complications (5%).
Conclusions: Otological disorders can co-occur in BPPV patients at a relatively high rate. These findings might contribute to understanding the diverse etiological factors underlying BPPV.
PPIII:18 - Post-traumatic benign paroxysmal positional vertigo: treatment outcome and clinical features
Byung-Kun Kim
1
1Nowon Eulji Medical Center, Neurology, Korea
Purpose: Head trauma is the most common cause of secondary benign paroxysmal positional vertigo (BPPV). However, the characteristics of post-traumatic BPPV (t-BPPV) have not been well studied. We investigated the clinical presentation, response to treatment, and short- and long-term outcomes of t-BPPV.
Methods: We reviewed the clinical records of 779 consecutive patients with BPPV from the Nowon Eulji Medical Center BPPV Registry. Patients with onset of positional vertigo within 14 days of trauma were included in the t-BPPV group. The clinical presentation, response to treatment, and short- and long-term outcomes of patients with t-BPPV were compared with those with idiopathic BPPV (i-BPPV) who were similarly treated and followed.
Results: Forty-eight (6.2%) of the 779 patients were diagnosed with t-BPPV. The mean age of t-BPPV was lower than that of i-BPPV (52.0 vs 55.8 years). Female gender and posterior canal involvement were more common in both t-BPPV and i-BPPV groups. Although there was no significant difference, bilateral involvement was more common in t-BPPV (4.2% vs 0.8%, p=0.08). The cure rate at 1 week was not different between the two groups (91.7% vs 92.3%). The mean follow-up for t-BPPV and i-BPPV was 23.2 and 28.3 months respectively. Although the short-term recurrence rate of t-BPPV at 3 months (10.4%) was higher than that of i-BPPV (4.8%), there was no recurrence in the t-BPPV group after 9 months.
Conclusions: Age is younger and bilateral involvement is more common in the t-BPPV group. Although t-BPPV shows early relapse, the long-term outcome of t-BPPV appears to be favourable.
PPIII:19 - Prevalence of BPPV in yoga practicing population
Pradeep Vundavalli1, Srinivas Dorasala2, Karthik Pervela1
1Asian ENT Hospital, Visakhapatnam, India
2Annayya Hospital, Bengaluru, Visakhapatnam
Purpose: The aim of the study is to know the prevalence of BPPV in the yoga practicing population. BPPV is a disorder of the semicircular canals due to the detached otoconia from Utricular macula. Indian population across all the ages who were practicing yoga on a daily basis atleast for 5 years were enquired about the attacks of bppv.
Methods: In multicentered study of the population of all the age groups, who were performing yoga atleast for 5 years were included in the study along with similar age group non yoga performing population. 650 subjects were included in the study who are performing yoga consistently for atleast 5 years. A similar number of people are included from the non yoga performing group and the prevalence of BPPV was assessed during a period of 3 years. Assessment was done at baseline (T1), at 18 months (T2) and at 36 months (T3)
Results: The prevalence of BPPV was found to be lesser in the yoga performing subjects when compared with non performers. At T1, T2, T3, group B ( non performers ) had a higher incidence of BPPV across all the age groups.
Conclusions: To conclude, yoga performers had less prevalence of BPPV when compared with non performers. Even in geriatric population, those who perform yoga consistently had lesser incidences of BPPV.
PPIII:21 - Recurrent BPPV - after treatment in repositioning chair
Tatjana Tomanovic
1
1Karolinska University Hospital, Department ENT, Hearing and Balance, Huddinge, Sweden
Purpose: The cause of BPPV is the presence of small dislodged otoconia particles within the semicircular canals. Canalith repositioning procedures (CRPs) have significantly changed the therapeutic approach to this condition and are typically performed on an examination bed. These procedures are highly effective. However, the efficacy of CRPs can vary depending on the subtype and location of BPPV. Despite this, 10–20 percent of patients do not respond to CRP. Some patients face physical limitations that prevent them from assuming the required head-hanging position during treatment. To address these challenges, various mechanical repositioning chairs have been developed. One such chair is the Rotundum® rotary chair (balcare GmbH, Küsnacht, Switzerland) (R-MRC), which we use in our Balance Department at Karolinska Hospital, Sweden. This MRC is equipped with VideoNystagmoGraphy (VNG) equipment, enabling precise monitoring of eye movements during treatment. BPPV treatment with this MRC has shown very high efficiency, with success rates reaching up to 97.1 percent.
Methods: Over a two-year period, we treated certain patients multiple times (3-6 times), and this report focuses on these cases. We analyzed 15 patients who were resistant to standard BPPV treatment in the Rotundum chair. The average age was 63 years (ranging from 42 to 81).
Results: Vestibular Head Impulse Test (VHIT) revealed a decrease in vestibulo-ocular reflex (VOR) gain, particularly in the posterior canal, indicating persistent BPPV in 13 patients. Caloric test shows patological caloric ration in 6 patients. Additionally, Hydration-Sensitive Magnetic Resonance Tomography (HYDRPS MRT) detected fluid flow disturbances in five patients.
Conclusions: Patients experiencing recurrent BPPV may have underlying vestibular organ disturbances beyond mechanical otoconial displacement. Therefore, it is crucial to employ a comprehensive test battery for both diagnosis and planing the therapy of persistent BPPV. In such cases, the term “recurrent positional paroxysmal vertigo” may be more appropriate.
PPIII:22 - Separating Benign Positional Vertigo from its mimics: a machine learning approach
Nicholas Yang1, Nicole Reid2, Emma Argaet3, Alyssa Dyball1, Andrew Bradshaw2, Sally Rosengren1, Allison Young3, Gnana Bharathy4, Mukesh Prasad4, Miriam Welgampola1
1The University of Sydney, Sydney, Australia
2Royal Prince Alfred Hospital, Sydney, Australia
3The Balance Clinic and Laboratory, Sydney, Australia
4University of Technology Sydney, Sydney, Australia
Purpose: Episodic positional vertigo caused by canalithiasis is identified by paroxysmal positional nystagmus in the plane of the affected canal and resolution with specific repositioning manoeuvres. Central vestibular disorders can also present with positional nystagmus. The aim of the study was to examine accuracy of machine learning models in differentiating the benign positional nystagmus of canalithiasis from BPPV mimics.
Methods: Video-nystagmography from patients tested on the Epley Omniax diagnosed with BPPV (n=334 posterior, n=111 horizontal canalithiasis) and patient with non-BPPV positional nystagmus ( n=10 posterior fossa tumors, n= 223 other central vertigo including vestibular migraine) were analysed using custom pupil tracking software. Nystagmus onset latency, peak slow phase velocity (SPV), SPV 50% rise time, peak latency, time to 50% and 95% drop in peak SPV: T50 and T95 were extracted from eye-position and velocity traces. 16 features were used for model development.
Results: For the canalithiasis and non-canalithiasis positional vertigo, the median onset latencies were 1.08 and 0.09s, time to peak SPV 2.92 and 7.05s, peak SPV 38.64 and 6.88 deg/sec, T50 3.3s and 6.24s and T95 9.96 and 15.83s with significant differences on Mann Whitney U Tests (p= 0.011-<0.001). The highest performing machine learning models: Random Forest, Decision Tree and XGboost yielded separation of canalithiasis from non-canalithiasis with 91-97% accuracy, 64-100% sensitivity, 96-100% specificity and 0.90-0.98 F1 scores.
Conclusions: The paroxysmal positional nystagmus of canalithiasis-BPV demonstrates a longer latency to onset, higher maximum/peak slow phase velocity, shorter rise and fall times compared with non-BPPV nystagmus. Machine Learning models accurately differentiate between BPPV and non-BPPV nystagmus profiles.
PPIII:23 - Spontaneous Reversing Positional Nystagmus as a sign of simultaneous ampullary and non-ampullary Posterior Canal BPPV
Andrea Castellucci1, Pasquale Malara2, Salvatore Martellucci3, Chiara Cocchi4, Angelo Ghidini1
1AUSL - IRCCS di Reggio Emilia, ENT Department, Reggio Emilia, Italy
2Centromedico, Audiology & Vestibology Service, Bellinzona, Switzerland
3AUSL di Latina, ENT Department, Latina, Italy
4University Hospital of Modena, Audiology Department, Modena, Italy
Purpose: Reversing positional nystagmus (RPN) represents an atypical positional nystagmus in BPPV as it spontaneously reverses its direction in the same position. The inversion of nystagmus has been related to different pathomechanisms including rebound cupular deflections, either peripheral or central short-term adaptation mechanisms of the VOR and coexistence of canalolithiasis and cupulolithiasis. Though it has been mainly described in lateral canal (LC)-BPPV, RPN can also occur in posterior canal (PC)-BPPV when paroxysmal upbeating nystagmus (pUBN) with ipsilesional torsional components is followed by persistent downbeating nystagmus (pDBN) in Dix-Hallpike test (DHT). Recently, the use of the vHIT has been recommended in the differential diagnosis of BPPV with pDBN (anterior canal-BPPV versus non-ampullary PC-BPPV) as it can detect endolymphatic flow dysfunctions due to an incomplete canalith jam in the affected canal. This study aims to provide possible etiopathogenetic hypotheses to explain RPN in PC-BPPV.
Methods: The records of 42 patients (5 males, 37 females, mean age 68.4±11.2 years) with PC-BPPV exhibiting RPN were retrospectively reviewed, including history of previous BPPV, nystagmus duration, presence of pDBN in contralateral DHT, canal VOR-gain values at the vHIT and the outcome of canalith repositioning maneuvers (CRM).
Results: Patients with reduced PC VOR-gain (62% of cases) exhibited higher rate of previous ipsilateral PC-BPPV (p<0.05), shorter first-phase pUBN (p<0.05), higher incidence of pDBN in contralateral DHT (p<0.001) and lower success rate of CRM (p<0.05) compared to the patients with normal PC VOR-gain. PC-VOR gain normalized in all cases with impaired values after symptoms resolution (p<0.001).
Conclusions: According to our data, in a consistent group of patients with PC-BPPV with RPN, the second-phase pDBN could be likely explained by the coexistence of an additional clot of debris partially entrapped in the non-ampullary arm of the PC, which results in bilaterally positive DHT and in slight PC impairment and prevents otolith reposition with CRM.
PPIII:24 - Study on 178 Probable Benign Paroxysmal Positional Vertigo patients
Koji Otsuka
1
1Sanno Hospital, Department of Otorhinolaryngology
Purpose: A problem occasionally encountered in clinical practice is the presence of a positive history of BPPV with a negative diagnostic maneuver for positional nystagmus. This type of vertigo might be classified as probable BPPV. The aim of the present study was to assess how many patients with probable BPPV convert into definite BPPV.
Methods: During 5 years, all consecutive patients with probable BPPV diagnosed at my former department were studied. Criteria of diagnosis were (1) history of repeated brief episodes of vertigo with changed in head position; (2) absence of detectable nystagmus during and after the Dix-Hallpike or spine roll test. Patients with only one visiting were excluded.
Results: One hundred and seventy-eight patients with probable BPPV were studied. Forty-nine patients (28%) with probable BPPV converted into definite BPPV during follow-up within 3 months. One hundred and twenty-nine patients (72%) with probable BPPV did not convert into definite BPPV.
BPPV canalolithiasis is known as the otoconia detached from the utricle moving along the canal wall by changing head position. The group of converting into definite BPPV, I suspected the otoconia temporary stagnated to somewhere in the canal. The other group of not converting into definite BPPV, I firstly suspected a small quantity of otoconia in the canal or on the cupula not provoking detectable nystagmus (subjective BPPV), secondary suspected another disease.
Conclusions: About 30% of probable BPPV converted into definite BPPV within three months. This result was less than expected.
PPIII:25 - Technology is Changing How We Manage Benign Paroxysmal Positional Vertigo
Amy R. Cassidy1, Michelle Petrak2, Susan L. Whitney1, Kamran Barin3
1University of Pittsburgh School of Health and Rehabilitation Sciences, USA: University of Pittsburgh Medical Center, Departments of Physical Therapy
2Interacoustics, Denmark
3The Ohio State University, Department of Otolaryngology Head & Neck Surgery, USA
Purpose: Advanced torsional eye tracking and IMU measurements were utilized to assess Benign Paroxysmal Positional Vertigo (BPPV) providing data for clinical decision making. Trends in the patterns of nystagmus were identified. One interesting pattern was a substantial torsional nystagmus on one side and a small, flat torsional nystagmus on the contralateral side.
Methods: Bilateral Dix Hallpikes were performed using VisualEyes torsional and IMU algorithms. The slow phase velocities of the torsional eye movements were recorded, along with horizontal and vertical eye movements.
Results: Left Dix Hallpike: an upward torsional nystagmus of large intensity and 10/10 dizziness score; Right Dix Hallpike: flat torsional nystagmus with initially 2/10 gradually increasing to 8/10 dizziness. The subject was treated with one modified Epley Maneuver on the left side. Bilateral Dix Hallpike maneuvers were repeated within the same session to reassess the nystagmus. The left Dix Hallpike showed no nystagmus and dizziness was reduced to 3/10 intensity. The repeat right Dix Hallpike showed no nystagmus, and the dizziness rating was 0/10.
Conclusions: It is not definitive as to why the patient had nystagmus during the Dix-Hallpike test bilaterally. Explanations could include debris on the short arm of the posterior canal, stimulation of debris on the contralateral side, or anterior canal involvement. The addition of torsional eye movements computerized analysis will be able to further help us understand these more complex cases of BPPV.
PPIII:26 - The differences between definite BPPV with clinical signs and suspected BPPV without those
Taishi Kii1, Kazuhiko Kubo2, Sohichiroh Moriya3
1National Hospital Organization Kyushu Medical Center, Department of Otorhinolaryngology & Head and Neck Surgery, JAPAN
2Chidoribashi General Hospital, Department of Otorhinolaryngology & Head and Neck Surgery, JAPAN
3Kyushu Central Hospital, Department of Otorhinolaryngology, JAPAN
Purpose: Benign paroxysmal positional vertigo (BPPV) is a most common cause of vertigo and dizziness. BPPV is diagnosed by the specific symptoms and nystagmus. However, severe vertigo sometimes prevents the patients with BPPV from a visit to medical institution. These patients are suspected BPPV but are not able to be diagnosed as BPPV definitely. The aim of this study is to detect the clinical differences between the definite BPPV with a specific nystagmus and suspected BPPV without that.
Methods: We recruited 255 subjects diagnosed as definite or suspected BPPV in our hospital from 2020 to 2022. The patients with nystagmus compatible to BPPV were diagnosed as definite BPPV while the patients were diagnosed as suspected BPPV who had a history like BPPV without nystagmus compatible to BPPV. The various parameters such as age, sex, drinking, smoking, complications and recurrence were collected from electric medical records retrospectively. The differences were statistically evaluated using JMP Pro 17. The current study was approved by our ethical committee.
Results: Hypertension and diabetes mellitus were more frequently in suspected BPPV group than in definite BPPV group. In contrast, recurrence of BPPV attack were more often in definite BPPV group than in suspected BPPV group.
Conclusions: There results suggest that vertigo/dizziness in the patients with suspected BPPV may not necessarily be caused by definite BPPV.
PPIII:28 - The use of technology in benign paroxysmal positional vertigo (BPPV) for customized intervention
Susan Whitney1, Michelle Petrak2, Amy Cassidy3, Kamran Barin4
1University of Pittsburgh, Department of Physical Therapy and Otolaryngology, USA
2Interacoustics, USA
3University of Pittsburgh Medical Center, Rehabilitation Institute, USA
4The Ohio State University, Department of Otolaryngology, USA
Purpose: The use of torsional algorithms for the analysis of BPPV is an emerging treatment option for the management of BPPV. Six locations have been identified in the literature where debris may be located within each semi-circular canal, making diagnosis and management more precise. The ability to record the torsional slow phase velocity during the Dix-Hallpike maneuver, roll test, and during the canalith repositioning maneuver (CRM) is showing that the “classic” pattern of torsional upbeating nystagmus towards the involved ear is much more complex than previously thought.
Methods: Recent evidence suggests that a few beats of positional nystagmus is common in persons without BPPV. We are only now starting to learn about the possiblity of short arm BPPV and what is happening in the less symptomatic ear with the use of new diagnostic tools to record torsion. Cases will be shown that illustrate debris in both canals that may affect patient outcomes.
Results: Eye movements, the slow phase velocity graphs, the perceived symptoms of the patients during the maneuvers, their Dizziness Handicap Inventory scores, their Activities-specific Balance Confidence scores, plus the resultant success or failure of the chosen CRM will be shown.
Conclusions: Torsional nystagmus may be seen in both ears during the Dix-Hallpike test, yet by performing the CRM on the more involved side, the nystagmus resolved on the uninvolved side.
PPIII:30 - Type 2 BPPV is commonly missed in chronic dizziness and imbalance
Joanna C. Jen1, Susan Feldman2, Susan L. Whitney3, Michael C. Schubert4, Jorge Kattah5, Miriam Welgampola6
1Icahn School of Medicine at Mount Sinai, Department of Neurology, U.S.A.
2Icahn School of Medicine at Mount Sinai, Department of Rehabilitation and Human Performance, U.S.A.
3University of Pittsburgh, School of Health and Rehabilitation Sciences, U.S.A.
4Johns Hopkins University School of Medicine Departments of Otolaryngology and Physical Medicine and Rehabilitation
5University of Illinois College of Medicine at Peoria, Department of Neurology, U.S.A.
6University of Sydney, Central Clinical School, Institute of Clinical Neurosciences, Royal Prince Alfred Hospital
Purpose: To improve the diagnosis and treatment of chronic dizziness and imbalance unresponsive to therapy with otherwise normal neurological function, this study critically analyzed patient questionnaires and medical records of 10 representative patients referred to a vestibular neurology clinic at a tertiary medical center from May 2023 to April 2024.
Methods: Patient questionnaires (presenting symptoms, their evolution, and self-reported quality of life), outcomes of prior medical assessment (diagnoses given, laboratory testing) and trialed treatments (medications and physical therapies), were reviewed. A neuro-otological examination was undertaken by a vestibular neurologist. The records were further reviewed and adjudicated by expert clinicians at multiple institutions.
Results: Ten patients were assessed, with age at onset spanning 12-69 years and duration ranging from 3 months to 6 years. Prior diagnoses included vestibular migraine (n=4), PPPD (n=3), superior canal dehiscence (n=2), vertebrobasilar insufficiency/compression (n=2), Meniere’s disease (n=1), and mal de debarquement syndrome (n=1). Six patients had vestibular therapy focused on gaze stabilization without repositioning. All patients reported initial positional dizziness suggestive of BPPV when interviewed. All reported subjective positional dizziness but no paroxysmal positional nystagmus was demonstrated on Dix-Hallpike testing. Eight patients reported improvement in response to repositioning maneuvers for the symptomatic ear; two experienced initial symptomatic exacerbation with subsequent improvement.
Conclusions: Our data suggest a missed initial diagnosis of BPPV, inadequate or missed treatment at symptom onset, and lingering Type 2 BPPV in chronic dizziness and imbalance that negatively impacted patients’ quality of life, with much anxiety leading to unnecessary laboratory testing without appropriate treatment for a potentially recurrent condition. Efforts are underway to systematically characterize patient cohorts from multiple institutions to assess the prevalence of Type 2 BPPV, track patient outcomes, and explore ways to improve the diagnosis and treatment of BPPV in chronic dizziness.
PPIII:31 - Unrecognized benign paroxysmal positional vertigo in frail in-patients
Ondrej Cakrt1, Klara Kucerova1, Sara Koutna1, Krystof Slaby1, Milan Kvapil2, Jaroslav Jerabek3
1Department of Rehabilitation and Sports Medicine, Second Faculty of Medicine, Charles University and Motol University Hospital, Czech Republic
2Department of Geriatrics, Second Faculty of Medicine, Charles University and Motol University Hospital, Czech Republic
3Department of Neurology, Second Faculty of Medicine, Charles University and Motol University Hospital, Czech Republic
Purpose: Dizziness is common complaint and its incidence increases with age. Dizziness is often associated with balance disorders and predispose a patient to falling, and falls in elderly patients are associated with high morbidity and mortality. Benign paroxysmal positional vertigo (BPPV) is an important cause which can easily be treated but is frequently not recognized by professionals. We sought to determine the prevalence of unrecognized BPPV in hospitalized elderly patients.
Methods: Patients who went to Geriatrics department of Motol University Hospital for regulary inpatient medical care were asked to participate in this study. Inclusion criteria included ability to communicated and no previous diagnosis of BPPV. The authors of study interviewed and examined all the patient. A questionnaire was used to obtain uniform and detailed history. A clinical neuro-otologic examination for Romberg test and spontaneous and gaze nystagmus was performed, as well as Dix-Hallpike and Supine-Roll test. Prevalence was tested with Fisher’s exact test.
Results: We evaluated a sample of 53 patients (17 men and 36 woman) during 3-month period. Their ages ranged from 49,6 to 95 years (78,8 ± 10,5, mean ± SEM). 27 (51 %) of these patients reparted fall in period of last six months and 25 (47 %) of patients reported dizziness. Possible or definite BPPV was found in 5 of 53 patients (9 %) patients. All patients suspected of BPPV reported dizziness in any situation, specifically after bending over and had sensation of spinning (all p<0,05), while only 3 of BPPV patients had dizziness after rolling in bed (p<0,05).
Conclusions: These data indicated that unrecognized BPPV is quite common in frail in-patient population and is always accompanied by symptoms.
PPIII:32 - Utility of guidelines on screening for Benign Paroxysmal Positional Vertigo in older adults who have fallen
Jeremy Corcoran1, Nicholas Hill1, Katie Noone2, Greg Thurlow1, Claire Potter1, Carys Williams2, Carrie-Ann Wood2, Natalie Thompson2, Lauren Shelvey1
1Guy’s Hospital, Multi-Disciplinary Balance Clinic, UK
2Guy’s Hospital, Multi-Disciplinary Falls Clinic, UK
Purpose: New international guidelines for falls management recommend that testing for benign paroxysmal positional vertigo (BPPV) should be undertaken if vertigo is reported by older adults who have fallen. However, vertigo may not be a sensitive subjective marker of BPPV. We investigated whether there is a relationship between a history of vertigo and presence of BPPV.
Methods: The physiotherapists in the Falls Clinic recorded the symptoms which patients, seen between January and October 2023, felt were most relevant to their falls. Patients were asked for further descriptions about symptoms interpretable as dizziness. The relationship between vertigo history (vertigo present vs absent) and BPPV status (BPPV present vs absent) was assessed by a Chi-square test on data derived from only those patients who underwent a Dix-Hallpike test in the Falls Clinic having had at least 1 fall in the preceding 12 months.
Results: Vertigo was documented as a relevant symptom of 7 patients. 5 of these (71%) were subjected to Dix-Hallpike tests. 2 patients were found to have signs of BPPV. 16 patients, who had not reported vertigo, were also subjected to positional testing. 1 had objective BPPV and another had convincing subjective BPPV. Chi square testing revealed no significant relationship between vertigo and BPPV, p = 0.17.
Conclusions: The null relationship between vertigo and BPPV suggests that vertigo may not be a sensitive marker of BPPV in older adult fallers. Screening for BPPV based on vertigo alone may lead to cases being missed, hence a cause of falls going undetected. Further data are to be collected to ensure the analysis and interpretation are as robust as possible.
PPIII:33 - Vitamin D supplementation in preventing the recurrence of benign paroxysmal positional vertigo
Tae Hoon Kong1, Dae Bo Shim2
1Yonsei University Wonju College of Medicine, Wonju Severance Christian Hospital
2Myongji Hospital, Hanyang University College of Medicine
Purpose: To evaluate thCe effect of vitamin D supplementation on the recurrence rate of benign paroxysmal positional vertigo(BPPV).
Methods: A single-center, prospective, double-blind, placebo-controlled, parallel-group randomized controlled trial was conducted between November 2018 and May 2020. After successful treatment with canalith repositioning maneuvers, patients diagnosed with BPPV were randomized to either the vitamin D (n = 20) or placebo (n = 18) group. Only patients with serum vitamin D levels <20 ng/mL were included. The vitamin D group received 7,000 IU of vitamin D weekly for a year, while the placebo group received a matching placebo drug. The final endpoint was the BPPV recurrence rate and correlation with serum vitamin D levels after 6 and 12 months in both groups.
Results: Among 38 patients, 37 were followed up for 6 months and 30 for 12 months. Significantly higher serum vitamin D levels were observed in the vitamin D group compared to the placebo group at both the 6-month and 1-year follow-ups (p<0.001 at each time point). The recurrence rate was lower in the vitamin D group than in the placebo group after 6 months (p=0.008) and 1 year (p=0.003).
Conclusions: Vitamin D supplementation, in the absence of calcium, may be beneficial for patients prone to recurrent BPPV episodes, particularly when serum vitamin D levels are suboptimal. (PRE20181024-001, Clinical Research Information Service, South Korea)
PPIII:34 - ‘EVESTA’ Emergency VESTibular Algorithm and its impact on the acute management of benign paroxysmal positional vertigo
Prue Neely1, Hemal Patel2, John McTaggart3, Stephen Bright2, Tom Wellings4
1Central Coast Local Health District, Physiotherapy Department, Australia
2Central Coast Local Health District, Emergency Department, Australia
3CiForum, New Zealand
4Hunter New England Local Health District, Neurology Department, Australia
Purpose: To synthesise evidence-based research concerning the assessment and management of acute dizziness via construction of a comprehensive clinical algorithm. Assess its clinical impact with an aim to improve the acute management of Benign Paroxysmal Positional Vertigo (BPPV) within Wyong Emergency Department (ED) in four key recommendations.
Methods: Current best practice models of care were synthesised into a single clinical, district based- peer reviewed algorithm by a specialist focus group. An observational pre and post implementation study was completed to assess the impact of the algorithm on the management of BPPV. A total of 162 notes (pre (control) n=87 and post (intervention) n=75) met the inclusion criteria. Adherence to the BPPV clinical practice guidelines statement 1a, 3a, 4a and 6 were analysed for statistical difference in practice between the two groups.
Results: Following implementation of ‘EVESTA’ compliance showed a significant improvement in Hallpike-Dix performed by 27% [95%CI (14-40%); defects pre-intervention 40%: post-intervention 13%] (p<0.001), utilization of neuroimaging reduced by 16% [95%CI (2-30%); 40%: 24%] (p<0.05), repositioning techniques performed increased by 33% [95%CI (18-48%); 68%: 36%] (p<0.001). Administration of vestibular suppressant medication reduced by 30% [95%CI (15-45%) 59%: 29%] (p<0.001). An interrupted time series analysis confirmed significant change in BPPV admissions post project -4.23% [95%CI (-7.20, -1.27%] (p=0.041).
Conclusions: Diagnosis and management of acute dizziness is challenging within the ED. Synthesis of best practice into a clinical algorithm has improved the diagnosis and evidence based treatment of BPPV. There is continued opportunity to improve the efficiency and effectiveness in the management of both central and peripheral acute dizziness within the ED.
6. Central Vestibular Disorders
PPIII:40 - A tour of the utriculo-ocular pathways through four clinical cases
Claire Allen1, Anand Bery2, Daniel Gold3
1Department of Neurology, Johns Hopkins Hospital
2The Johns Hopkins Hospital, Department of Neurology, Baltimore, MD, United States
3The Johns Hopkins Hospital, Departments of Neurology, Ophthalmology, Neurosurgery, Otolaryngology - Head & Neck Surgery, Emergency Medicine, and Medicine, Baltimore, MD, United States
Purpose: The utriculo-ocular pathway has specific neuro-anatomic localization, from the utricle to the ipsilateral vestibular nerve and nucleus, decussation at the ponto-medullary junction, ascent in the contralateral medial longitudinal fasciculus, to finally reach the interstitial nucleus of Cajal (INC). Dysfunction anywhere along this pathway can cause the pathologic ocular tilt reaction (triad of ocular counterroll [OCR], head tilt, and skew deviation). Here, we highlight the localizing value of peripheral and central utriculo-ocular pathways by walking through four sequenced illustrative clinical cases (with fundus images and/or clinical videos). Each case serves as a “waystation” along the same pathway originating in the right ear and ending in the left midbrain, to demonstrate how different anatomic lesions (in some cases, across the midline) can yield similar clinical findings.
Methods: We outline four clinical cases from https://novel.utah.edu/Gold/
Results: We present cases of: (1) Acute right-sided vestibular neuritis causing OCR towards the lesioned right side (top pole of each eye rotated towards the ipsilateral right ear). (2) Right lateral medullary syndrome causing OCR towards the lesioned right side (3) Ischemic stroke involving the left INC causing OCR away from the lesioned left side (top pole of each eye rotated towards the contralateral right ear) (4) Paroxysmal OCR from hemosiderin deposition in the left INC, in a patient who had prior hemorrhage in that location
Conclusions: A series of real cases, arranged anatomically, will help clinicians understand the utriculo-ocular pathway, its peripheral and central anatomy, and its helpful bedside localizing value.
PPIII:41 - Abnormal eye movements in a case of autoimmune cerebellar ataxia associated with anti-glutamine decarboxylase antibodies
Rie Naito1, Yuki Watanabe1, Akira Naito1, Keiko Sugasawa1, Kazushi Takahashi2
1Tokyo Metropolitan Neurological Hospital, Department of Neuro-otology, Japan
2Tokyo Metropolitan Neurological Hospital, Department of Neurology, Japan
Purpose: Glutamine decarboxylase (GAD) is an enzyme that catalyzes the conversion of glutamate to gamma-aminobutyric acid (GABA), which is the inhibitory neurotransmitter in the central nervous system. Although the pathogenic role of anti-GAD antibodies (anti-GAD-ab) is still debated, anti-GAD-ab have been associated with cerebellar ataxia, which are considered to result from reduced GABAergic transmission. Abnormal eye movements in anti-GAD-ab positive cerebellar ataxia are not well documented. At this meeting we will report on abnormal eye movements in a case of anti-GAD-ab positive cerebellar ataxia.
Methods: Presentation of case; female aged 75 years. She had been complained of a floating sensation and staggering when walking. A brain MRI revealed mild cerebellar atrophy and high levels of anti-GAD-ab, and a neurologist diagnosed anti-GAD-ab-positive cerebellar ataxia. Neuro-otological examinations (gaze nystagmus, positional nystagmus, positioning nystagmus, smooth pursuit, saccades, optokinetic nystagmus, caloric testing and visual fixation suppression test) have been performed nine times for five years on each admission for treatment purposes.
Results: She had gaze nystagmus, downbeat nystagmus, saccadic and dysmetric pursuit, hypometric saccades and prolonged latency of saccades. She also developped decreased maximum slow-phase velocity of optokinetic nystagmus and visual fixation suppression values, which fluctuated and worsened over the course of the disease.
Conclusions: During the course of treatment, progressive cerebellar and brainstem dysfunction was observed in a fluctuating manner, suggesting progressive reversible and/or irreversible damage to the cerebellum and cerebellar input-output systems caused by anti-GAD-ab through an autoimmune mechanism. This results of the eye movement abnormalities are consistent with the theory that anti-GAD-ab may affect GABAergic transmission.
PPIII:42 - Assessment of vestibulo-ocular reflex in spinocerebellar ataxia type 7
Jae-Myung Kim1, Hyunsoo Kim1, Beom-Seok Seo1, Ye-Eun An1, Jong-Hee Choi1, Seong-Min Hong1, Seong-Min Choi1, Seung-Han Lee1
1Chonnam National University Hospital and Chonnam National University Medical School, Department of Neurology, South Korea
Purpose: Vestibulo-ocular reflex (VOR) impairment in spinocerebellar ataxia (SCA) is common, but the pattern varies between subtypes. Among them, vestibular performance in SCA7, one of the major subtypes, has rarely been studied.
Methods: A total of 10 genetically confirmed SCA7 patients [men=4; mean age=37(17-56)] were enrolled. Clinical characteristics, neuro-otological and neuro-ophthalmological evaluations were performed. To investigate VOR, the video head impulse test (vHIT) was checked in all patients. Bithermal caloric stimulation was also performed in eligible patients (n=4). Normative data were obtained from 36 age- and gender-matched controls.
Results: In all 10 patients, nine patients (90%) showed saccadic slowing, but spontaneous or induced nystagmus were absent. Compared to control group, the VOR gains in SCA7 were decreased for both vertical canals [anterior canals, ACs, 0.38 (median), p<0.001; posterior canals, PCs, 0.52, p<0.001] during vHIT. However, abnormal catch-up saccades were absent in the corresponding (vertical) canals. Also, the VOR gains for the AC were negatively correlated with disease severity (R=0.952, p<0.001). Follow-up vHIT (n=5/10) demonstrated persistent VOR impairments in the ACs (p=0.028) and PCs (p=0.046). Of interest, three patients (3/4, 75%) showed decreased bithermal caloric responses without horizontal canal gain impairments during vHIT.
Conclusions: In our study, vertical canal-dominant high-frequency VOR impairments were common in SCA7. Moreover, several patients demonstrated discordant results depending on the stimuli frequency. Although the pathomechanisms of vestibular performance in SCA7 are largely unknown, these distinctive results may aid the differential diagnosis of the SCA genotypes and better understanding of the neuropathology of the SCAs.
PPIII:43 - Bilateral Peripheral Vestibular Loss and Ataxia: a Novel Presentation of a Rare Mutation DNMT1
David Rastall
1
1Johns Hopkins, Department of Neurology, Neruovisual and Vestibular Division
Purpose: Ataxia with bilateral vestibular loss and peripheral neuropathy with a family history is a typical presentation of cerebellar ataxia, neuropathy, vestibular areflexia syndrome (CANVAS). We present an alternative genetic condition presenting this way mediated by a mutation in DNA-methyltransferase 1 (DNMT1).
Methods: vHIT, VOG, and NGS were used.
Results: A 50 y.o. woman presented with 20 years of gait instability attributed to EMG-confirmed peripheral neuropathy. In her 40’s she developed idiopathic bilateral hearing loss. She presented for episodic vertigo. She developed a constant vertical oscillopsia and associated vertigo, nausea, vomiting and worsening of her gait worse when looking at LEDs or signs in the dark. On review she had a family history in her mother's father, mother, and both brothers, all of whom died at young ages from an undiagnosed neurological disorder of imbalance and vertigo. On exam she had a significant neck tremor and bilateral peripheral vestibular loss with vHIT gains ∼0.5 bilaterally and both overt and covert catch up saccades indicating acute and chronic peripheral vestibular damage. Her gait showed components of a sensory ataxia and a cerebellar ataxia, and her eye movements similarly localized to the cerebellum with a lateral gaze evoked nystagmus with rebound nystagmus and a down-beating nystagmus brought on by lateral gaze. With bilateral vestibular loss, cerebellar ataxia, and peripheral neuropathy, CANVAS was suspected, however genetic testing was negative. Subsequent testing revealed a novel mutation in DNA-methyltransferase 1 (DNMT1). Of note, most of her vertigo and oscillopsia was due to loss of VOR with associated neck tremor, and stabilizing her neck was significant for removing her oscillopsia and vertigo.
Conclusions: DNMT1 is integral to inner ear function in mice and has been reported to cause deafness, but to our knowledge this is the first report of bilateral vestibular loss, ataxia, and peripheral neuropathy together due to DNMT1.
PPIII:44 - Defining the Hyperactive Vestibular System: A Pilot Study
Anna Mangano1, Andrew Senchak2
1Baylor Scott and White Institute for Rehabilitation, Frisco USA
2Texas Ear and Vestibular Institute
Purpose: The purpose of this study is to better understand patients with vestibular disorders who have often been deemed as “central” in their origin. This term is broad and encompasses conditions such as vestibular migraine (VM), persistent postural perceptual dizziness (PPPD), mal de debarquement syndrome (MDDS), among others. Patients with chronic dizziness do not fit into the well defined peripheral vestibulopathies. These patients have a large economic impact on the healthcare system as they search for answers. In our practice settings we have defined these patients as having a “hyperactive” vestibular system. Hypothesis: Individuals with a hyperactive vestibular system will have higher time constants, gain, nystagmus with calorics and self reported DHI scores.
Methods: Data was collected in two groups, those with diagnosed PPPD or BPPV. 8 individuals in each group were used for the pilot data. Time constant and gain data were collected with rotation chair testing. Nystagmus was measured during caloric testing and all patients filled out a DHI upon entry to Physical Therapy. A paired t-test was run on each of the data to determine if there were significant differences between groups.
Results: Time constant: t(7)=2.757, p=0.0077 DHI: t(7) =1.987, p=0.03 Gain: t(7) =0.648, p=0.264 Nystagmus: t(7)=0.343, p=0.368.
Conclusions: This data suggests that persons diagnosed with PPPD have significantly more motion encoding by the vestibular system which could explain the “visual vertigo” component of the diagnosis. Higher DHI scores indicate more severe subjective dizziness with PPPD, which correlates with higher motion encoding. Lastly, gain and nystagmus indicate that the peripheral vestibular system is functioning the same between diagnoses. This data describes a hyperactive vestibular system for differential diagnosis of vestibulopathy.
PPIII:45 - Detailed vestibular function in a patient of CANVAS
Shintaro Yamazaki1, Keita Tsukada1, Kentaro Hori1, Kentaro Mori1, Yutaka Takumi1
1Shinshu University, Department of Otorhinolaryngology Head and Neck Surgery, Japan
Purpose: CANVAS (cerebellar ataxia with neuropathy and vestibular areflexia syndrome) is a slowly progressive syndrome with bilateral vestibular dysfunction, cerebellar ataxia, and sensory neuropathy, which was first reported by Szmulewics et al. in 2011. In this report, we show detailed vestibular function in a patient of CANVAS and reviewe the literature.
Methods: Case: A 62-year-old man. He had been aware of instability in the standing position since around age 50, and had difficulty in climbing stairs since age 61. MRI scan showed cerebellar atrophy. Neurological examination revealed cerebellar ataxia, and nerve conduction studies showed sensory neuropathy. These results suggested spinocerebellar degeneration (SCD) with sensory neuropathy or CANVAS. Therefore, the patient was given a detailed vestibular function examined.
Results: In vestibular function, we found bilateral canal paresis by caloric test, no response in cervical Vestibular Evoked Myogenic Potential (cVEMP) bilaterally, and decreased oVEMP results in the left ear. Video Head Impulse Test (v-HIT) showed reduced VOR gain except in the right lateral semicircular canal, and the presence of catch-up saccades except in the bilateral anterior semicircular canals. The results of vestibular testing revealed bilateral vestibular dysfunction. Based on these findings, a diagnosis of CANVAS was made. Additional genetic testing showed a mutation in the RFC1 gene.
Conclusions: In this case, bilateral vestibular dysfunction was observed in caloric test, v-HIT and cVEMP. Previous histopathological reports have shown that degeneration of bilateral vestibular ganglion were observed in patients with CANVAS, which is thought to cause the abnormal results of vestibular tests.
CANVAS is a disease that should be recognized by otolaryngologists because bilateral vestibular dysfunction is included in its diagnostic criteria.
PPIII:46 - Differential diagnosis of unidirectional horizontal nystagmus in acute vestibular syndrome
Ken Johkura1, Takashi Jono1, Kazumitsu Amari2, Koji Takahashi3
1Yokohama Brain and Spine Center, Neurology, Japan
2Yokohama Brain and Spine Center, Neurosurgery, Japan
3Yokohama Brain and Spine Center, Clinical Laboratory, Japan
Purpose: Isolated vertigo with unidirectional horizontal nystagmus (UHN) is usually caused by acute unilateral peripheral vestibular disorders. However, it may also be caused by central disorders. The purpose of this study is to establish a simple method to differentiate UHN with central and peripheral disorders in patients with isolated vertigo.
Methods: This study included patients with isolated vertigo of central (n = 16) or peripheral (n = 60) origin who presented with UHN. Video-oculography was used to measure the slow-phase velocity of nystagmus in each lateral position during the supine head-roll test. Then, we compared the direction of nystagmus in the lateral position where nystagmus is stronger (slow phase velocity is 30% or more faster) than the other lateral position in central and peripheral vertigo.
Results: In patients with central lesions, stronger lateral-positional nystagmus was directed apogeotropically in all patients. However, in patients without central lesions, stronger lateral-positional nystagmus was directed geotropically in 59%; in these patients, results of vestibular tests (vHIT and VEMP) indicated unilateral anterior and lateral semicircular canal and utricle disorders. In another 13%, stronger lateral-positional nystagmus was directed apogeotropically. In the remaining 28%, nystagmus intensity was similar in both lateral positions.
Conclusions: In patients with UHN, when stronger lateral-positional nystagmus is apogeotropic, it may be of central origin. However, when stronger lateral-positional nystagmus is geotropic, it is not of central origin, and suggesting superior vestibular neuritis.
PPIII:47 - Dorsolateral Caudal Pontine Infarction: Distinct Vestibular Syndrome and Eye Movement Abnormalities
Hyun Sung Kim1, Eun Hye Oh2, Seo Young Choi3, Kwang-Dong Choi3, Yujin Lee2, Jae-Hwan Choi2
1Department of Neurology, Gyeongsang National University Changwon Hospital, Changwon, South Korea
2Department of Neurology, Pusan National University School of Medicine, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, South Korea
3Department of Neurology, Pusan National University Hospital, Pusan National University School of Medicine and Biomedical Research Institute, Busan, South Korea
Purpose: The aim of this study was to investigate the distinct vestibular and ocular motor abnormalities in dorsolateral caudal pontine (DLCP) infarction, and determine their anatomical correlation.
Methods: Of the 506 patients with pontine infarctions in the stroke registry of Pusan National University Yangsan Hospital, 18 patients with unilateral DLCP lesions (17 with cerebral infarction and one with cavernous malformation) were subjected to analyses of clinical features, and results of neuro-otological evaluations and neuroimaging.
Results: Most patients (16/18, 89%) presented with an isolated acute vestibular syndrome (AVS). DLCP lesions were classified into three groups based on abnormal vestibular and ocular motor findings with their anatomical correlation: (1) Group I (inferior cerebellar peduncle [ICP] or nodulus type, 22% [4/18]): ipsilesional spontaneous nystagmus without direction-changing gaze-evoked nystagmus (GEN), normal head impulse tests (HITs) and caloric response, and contraversive subjective visual vertical (SVV) tilt or ocular-tilt reaction (OTR); (2) Group II (vestibular nucleus type, 50% [9/18]): contralesional spontaneous nystagmus, direction-changing GEN, abnormal HITs or caloric paresis, and ipsiversive SVV tilt or OTR; (3) Group III (flocculus type, 28% [5/18]): ipsilesional spontaneous nystagmus, direction-changing GEN, abnormal HITs, and normal caloric response. Initial MRIs with diffusion-weighted images (< 48 hours) were falsely negative in 41% (7/17) of DLCP infarction.
Conclusions: DLCP infarction commonly leads to an isolated AVS with distinct vestibular and ocular motor abnormalities, which can be classified into three groups based on anatomical correlation.
PPIII:48 - Evaluation of a multimodal diagnostic algorithm for prediction of cognitive impairment in elderly dizzy patients
Karim Felfela1, Nima Jooshani1, Ken Möhwald2, Doreen Huppert1, Sandra Becker-Bense1, Florian Schöberl3, Roman Schniepp1, Filipp Filippopulos1, Marianne Dieterich2, Max Wühr1, Andreas Zwergal2
1LMU University Hospital, German Center for Vertigo and Balance Disorders (DSGZ), Munich, Germany
2LMU University Hospital, German Center for Vertigo and Balance Disorders (DSGZ) & Department of Neurology, Munich, Germany
3LMU University Hospital, Department of Neurology, Munich, Germany
Purpose: The current diagnostic workup for chronic dizziness in elderly patients often neglects neuropsychological assessment, thus missing a relevant proportion of patients, who perceive dizziness as a subjective chief complaint of a concomitant cognitive impairment. This study aimed to establish risk prediction models for cognitive impairment in chronic dizzy patients based on data sources routinely collected in a dizziness center.
Methods: One hundred patients (age: 74.77.1years, 41.0% women) with chronic dizziness were prospectively characterized by 1) neuro-otological testing, 2) quantitative gait assessment, 3) graduation of focal brain atrophy and white matter lesion load, and 4) cognitive screening (MoCA). A linear regression model was trained to predict patients’ total MoCA score based on 16 clinical features derived from demographics, vestibular testing, gait analysis, and imaging scales. Additionally, we trained a binary logistic regression model on the same data sources to identify those patients with a cognitive impairment (i.e., MoCA < 25).
Results: The linear regression model explained almost half of the variance of patients’ total MoCA score (R2=0.49; mean absolute error: 1.7). The most important risk-predictors of cognitive impairment were age (β=-0.75), pathological Romberg’s sign (β=-1.05), normal caloric test results (β=-0.8), slower timed-up-and-go test (β=-0.67), frontal (β=-0.6) and temporal (β=-0.54) brain atrophy. The binary classification yielded an area under the curve of 0.84 (95% CI: 0.70-0.98) in distinguishing between cognitively normal and impaired patients.
Conclusions: The need for cognitive testing in patients with chronic dizziness can be efficiently approximated by available data sources from routine diagnostic workup in a dizziness center.
PPIII:49 - Galvanic vestibular stimulation in the treatment of Mal de Debarquement Syndrome: proof-of-concept study
Catho Schoenmaekers1, Dario De Smet1, Andrzej Zarowski2, Choi Deblieck1, Floris Wuyts1
1Lab for Equilibrium Investigations and Aerospace, University of Antwerp, Antwerp, Belgium
2European Institute for ORL-HNS, Sint-Augustinus hospital, Wilrijk, Belgium
Purpose: Mal de Debarquement Syndrome (MdDS) is a central vestibular disorder characterized by the perception of self-motion (swaying, rocking, bobbing, and/or gravitational pull). Despite various theories proposing potential underlying mechanisms, the pathophysiology of MdDS remains unclear. Interestingly, MdDS patients typically find relief from their symptoms while in motion, such as when riding in a car or train, only for the symptoms to reemerge upon cessation of movement. In this proof of concept study, we aim to explore the potential of galvanic vestibular stimulation (GVS) as a viable treatment option for MdDS, to mitigate MdDS symptoms, complementary to the current treatment options, like the VOR readaptation treatment. We propose that GVS may offer relief by simulating movement and deceiving the vestibular organs. By transmitting appropriate signals (mA currents), GVS could induce a sensation of self-motion even during periods of rest. This simulation could help alleviate the persistent oscillatory motion experienced by MdDS patients, countering the continuous internal sensation of movement. Essentially, GVS may disrupt or suppress the internal “noisy” oscillatory signal, comparable to the relief experienced by MdDS patients while traveling in a car. Our clinical trial proof-of-concept study involves applying GVS in 12 MdDS patients during 2 consecutive days. We collect visual analogue scale and posturography measurements before and after each stimulation session. Currently, 7 of the 12 patients have been enrolled. Preliminary analysis is very promising. Full results will be presented at the Barany Society meeting in Uppsala.
Methods:
Results:
Conclusions:
PPIII:50 - Mal de débarquement syndrome long-term follow-up after readaptation of the vestibulo-ocular reflex
Catherine Cho1, Sergei B. Yakushin2, Jun Maruta2, Theodore Raphan3
1NYU Langone Medical Center
2Icahn School of Medicine at Mount Sinai
3Brooklyn College
Purpose: Mal de débarquement syndrome (MdDS) is a chronic and debilitating vestibular disorder manifested by a persistent false sensation of non-spinning self-motion. The chance of a positive outcome of MdDS improved significantly with the recent discovery that velocity storage, a central vestibular mechanism and major element of the vestibulo-ocular reflex (VOR), may be maladapted in MdDS. A treatment protocol designed to induce readaptation of the VOR was clinically applied to 630 patients in our laboratory in 2014-2019. We aimed to evaluate the long-term efficacy of the treatment.
Methods: We re-contacted the former patients to conduct a follow-up survey of their symptom status. The outcome measure was an overall symptom rating on a 0-10 scale (0, no symptoms; 10, the most difficult imaginable of combined symptoms). We considered a clinically significant improvement to be more than a halving of the rating relative to pre-treatment.
Results: A total of 462 patients (82% women) responded to the survey 6 to 109 months post-treatment. The treatment initially yielded a successful outcome with a significant symptom improvement in 70.6% of the patients. In either successfully or non-successfully treated patients, time to follow-up did not correlate with the long-term symptom status, i.e., there was no systematic spontaneous recovery. At the time of follow-up, 63% of successfully treated patients still reported a significant improvement relative to the pre-treatment level, a rate significantly higher than a 50-50 chance (p<0.001).
Conclusions: Although the risk of symptom recurrence remains after VOR readaptation, the treatment yields overall positive long-term outcomes in patients with MdDS.
PPIII:54 - Saccades and Convergence Tests Analysis in Patients with Multiple System Atrophy and Parkinson’s Disease
Xia Ling1, Xinyan Ma2, Qianqian Wang2, Yuan Xu2, Yuexia Wu2, Jianrong Wang2, Kangzhi Li3, Fan Li1, Xu Yang2, Zhaoxia Wang1
1Peking University First Hospital, Department of Neurology, China
2Peking University Aerospace School of Clinical Medicine (Aerospace Center Hospital), Department of Neurology, China
3Peking University Shougang Hospital, Department of Neurology, China
Purpose: To describe the oculomotor features in patients with multiple system atrophy (MSA) and Parkinson’s disease (PD).
Methods: 32 MSA and 55 PD patients underwent detailed clinical eye movement examination, including saccades and convergence tests.
Results: During the horizontal saccade test, 19 (59.4%) MSA and 14 (25.5%) PD patients exhibited prolonged latency (P = 0.005). Among MSA patients, fifteen patients showed hypometria saccades that was bidirectional in nine, unidirectional in six, while in PD patients, fifteen patients showed hypometria saccades that was bidirectional in twelve, unidirectional in three (P = 0.104). Among MSA patients, 5 patients showed slowing horizontal saccades that was bidirectional in three, and unidirectional in two, while in PD patients, 1 case (1.8%) showed unidirectional slowing of horizontal saccades (P = 0.024). Twenty-one (65.6%) MSA and 14 (25.5%) PD patients showed prolonged latency of vertical saccades (P < 0.001). One (1.8%) PD and 6 (18.8%) MSA patients demonstrated hypermetria of vertical saccades (P = 0.017). Among MSA patients, seven patients showed slowing vertical saccades that was bidirectional in four, downward in two, and upward in one, while in PD patients, 1 case (1.8%) showed slowing upward saccades (P = 0.001). Fourteen MSA patients showed impaired convergence, and six patients exhibited convergence-induced nystagmus, whereas among PD patients, 10 showed impaired convergence, and one patient exhibited convergence-induced nystagmus (P < 0.001).
Conclusions: Compared to PD, MSA shows more prominent prolonged latency and hypermetria of saccades, as well as impaired convergence, suggesting potentially pronounced brainstem and cerebellar involvement in MSA.
PPIII:55 - Small Strokes, Subtle Findings, ED VOG-HINTS Saves the Day!
Claire Allen1, Anand Bery1, David Hale1, Ali Saber Tehrani1, Daniel Gold2
1Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
2Department of Neurology, Neurosurgery, Ophthalmology, Otolaryngology - Head and Neck Surgery, Emergency Medicine, & Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
Purpose: Vestibular testing including video-oculography (VOG) and video head impulse testing (vHIT) have aided in the diagnosis of small strokes (a few millimeters in size) in patients with ambiguous history and unremarkable general neurologic exam. Our battery of VOG testing in the emergency department has changed management for several patients for whom the MRI was initially read as normal and the diagnosis of stroke could otherwise have been missed. Based on our localization, DWI positive lesions were able to be identified upon re-review of the MRI by our team, stroke neurology and neuroradiology.
Methods: We describe the subtle ocular motor findings in 3 patients who were found to have small medullary and cerebellar strokes.
Results: - For all cases, VOG test of skew and vHIT gains were normal.
Case 1:
History: 4 days of intermittent swaying.
Neurology consult: normal HIT, left beating nystagmus (LBN), normal MRI, vestibular neuritis diagnosed.
VOG findings and recommendation: spontaneous LBN, normal vHIT; re-read MRI.
MRI: right medullary stroke.
Case 2:
History: 2 hours of acute onset dizziness.
Neurology consult: abnormal HIT to the right and LBN.
VOG findings and recommendation: spontaneous LBN, vHIT showed corrective saccades with normal gain to the right; re-read MRI.
MRI: right medullary stroke.
Case 3:
History: 2 weeks of intermittent headache and dizziness.
Neurology consult: No nystagmus.
VOG findings and recommendation: saccadic smooth pursuit, spontaneous RBN, head-shaking induced LBN; MRI ordered.
MRI: right paraflocculus stroke.
Conclusions: Case 1- VOG-HINTS strongly suggested central etiology, review of the MRI identified an initially missed DWI lesion. Case 2- normal vHIT gains confirmed central HINTS despite corrective saccades seen at the bedside, review of MRI identified an initially missed DWI lesion. Case 3- subtle spontaneous nystagmus (peak slow phase velocity < 1-2 degrees per second) and localizing ocular motor findings were only appreciated on VOG.
PPIII:56 - Spontaneous Nystagmus Violating the Alexander’s Law in Wallenberg Syndrome: Characteristics and Mechanisms
Jae-Hwan Choi1, Eun Hye Oh1, Hyun Sung Kim2, Ji-Yun Park3, Suk-Min Lee4, Seo Young Choi4, Hyo Jung Kim5, Jeong-Yoon Choi6, Ji-Soo Kim6, Jorge Otero-Millan7, Kwang-Dong Choi4
1Department of Neurology, Pusan National University School of Medicine, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, South Korea
2Department of Neurology, Gyeongsan National University School of Medicine and Gyeongsang National University Changwon Hospital, Changwon, South Korea
3Department of Neurology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, South Korea
4Department of Neurology, Pusan National University Hospital, Pusan National University School of Medicine and Biomedical Research Institute, Busan, South Korea
5Biomedical Research Institute, Seoul National University Bundang Hospital, Seongnam, South Korea
6Department of Neurology, Seoul National University College of Medicine, Dizziness Center, and Clinical Neuroscience Center, Seoul National University Bundang Hospital, Seongnam, South Korea
7Herbert Wertheim School of Optometry and Vision Science, University of California, Berkeley, California, USA
Purpose: This study aimed to elucidate the characteristics and mechanisms of spontaneous nystagmus violating the Alexander’s law.
Methods: We measured the mean and slope of slow-phase velocities (SPVs) and time constant of nystagmus during the straight ahead and lateral gaze in 17 patients with Wallenberg syndrome and violation of the Alexander’s law. Twenty patients with vestibular neuritis served as a control. We also implemented a mathematical model to simulate the nystagmus violating Alexander’s law.
Results: Patients showed a violation of Alexander’s law in one or both directions of lateral gaze. When Alexander’s law is violated, the Tc was larger than that in the controls (median [IQR]: 14.4 s [6.4-38.9] vs 9.0 s [5.5-12.6], p=0.036) while the Tc did not differ between the groups when Alexander’ law is obeyed (9.6 s [3.6-16.1] vs 9.0 s [5.5-12.6], p=0.924). Three patients showed nystagmus with an increasing SPV (n=3) or centripetal nystagmus (n=1) during lateral gazes, both of which indicate an unstable neural integrator. In a mathematical model with normal integrator function, the false rotational cue generates nystagmus following Alexander’s law. The first lesion, which changes the brainstem neural integrator, and the second lesion, which causes the Purkinje synapse to exert excitatory input, both lead to nystagmus that violates Alexander’s law.
Conclusions: We propose that when the neural integrator is unstable with lesions in the brainstem neural integrator itself or the neural synapse between Purkinje cells and the brainstem vestibular nucleus, nystagmus violates Alexander’s law.
PPIII:58 - Symptoms, diagnosis and vestibular rehabilitation in Chiari Malformation: A Case Report
Diana Mihai-Coman
1
1Clinica Nova Explorari ORL, Cluj-Napoca, Romania
Purpose: Chiari malformation represents a complex neurosurgical entity, often accompanied by a spectrum of audio-vestibular manifestations, including vertigo, disequilibrium, tinnitus, headache, and cervical stiffness. This study aims to delineate the therapeutic impact of vestibular rehabilitation in conjunction with pharmacological modalities in mitigating vestibular symptoms in a single case of type 1 Chiari malformation.
Methods: A case report was conducted involving a 49-year-old patient initially misdiagnosed with vestibular migraine, later diagnosed with type 1 Chiari malformation via MRI. Subsequent to a comprehensive audio-vestibular evaluation, the patient embarked on a tailored regimen comprising vestibular rehabilitation exercises, conservative physiotherapy, and pharmacological intervention.
Results: Significant enhancements in quality of life were observed at 1-month and 3-month evaluations. Symptoms including dizziness, instability, headache, neck stiffness, and hand numbness showed marked improvement. The results underscore the effectiveness of vestibular rehabilitation and conservative physiotherapy, in combination with medication, in ameliorating symptoms and enhancing quality of life in Chiari malformation.
Conclusions: Accurate recognition and management of vestibular manifestations in Chiari malformation are paramount, given their considerable impact on patient well-being. The amalgamation of vestibular rehabilitation, conservative physiotherapy, and pharmacological interventions emerges as a cornerstone in optimizing therapeutic outcomes and augmenting the quality of life for individuals afflicted with Chiari malformation. Future investigations, involving expanded cohorts, are warranted to validate and extrapolate these findings comprehensively.
PPIII:60 - Triggered Saccadic Oscillations : Characteristics and Possible Mechanisms
Eun Hye Oh1, HyCun Sung Kim2, Seo Young Choi3, Kwang-Dong Choi3, Jae-Hwan Choi1
1Department of Neurology, Pusan National University School of Medicine, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, South Korea
2Department of Neurology, Gyeongsang National University Changwon Hospital, Changwon, South Korea
3Department of Neurology, Pusan National University Hospital, Pusan National University School of Medicine and Biomedical Research Institute, Busan, South Korea
Purpose: Saccadic oscillations (SOs) mostly occur spontaneously, but can be occasionally triggered by various stimuli. This study aimed to determine clinical characteristics and underlying mechanisms of triggered SOs.
Methods: We analyzed the clinical features and quantitative eye-movement recordings of six patients with triggered SOs. Additionally, we reviewed the findings of 10 patients previously published in the literature.
Results: Patients with triggered SOs had lesions primarily involving the cerebellum and/or brainstem (11/16, 69%). Other causes were vestibular migraine (2/16), multiple sclerosis (1/16), and Krabbe disease (1/16). Vestibular stimulation was the most common trigger (11/16, 69%), followed by removal of visual fixation (4/16, 25%), hyperventilation (1/16), light (1/16), and blink (1/16). The types of triggered SOs were varied which included ocular flutter (13/16), opsoclonus (3/16), vertical SOs (2/16), and macrosaccadic oscillations (1/16). Three patients exhibited downbeat nystagmus either before (n=1) or after (n=2) the onset of SOs. The frequency of triggered SOs ranged from 4 to 15 Hz, and oscillations with smaller amplitudes had higher frequencies and smaller peak velocities.
Conclusions: SOs can be triggered by the modulation of unstable saccadic neural networks through vestibular and visual inputs in lesions of the brainstem and cerebellum.
PPIII:62 - Vestibular and imaging characteristics of individuals with infratentorial superficial siderosis: a cross-sectional study
N Kharytaniuk1, N Koohi2, J Patel3, Y Sammaraiee4, SF Farmer5, P Cowley6, D Kaski2, AM Bronstein7, AGM Schilder8, DJ Werring4, D-E Bamiou1
1Ear Institute, University College London, London, UK
2Department of Clinical and Movement Neurosciences, Queen Square Institute of Neurology, University College London, London, UK
3Department of Neuro-otology, Royal ENT and Eastman Dental Hospitals, University College London Hospitals NHS Foundation Trust, London, UK
4Stroke Research Centre, Department of Brain Repair and Rehabilitation, Queen Square Institute of Neurology, University College London, London, UK
5Department of Neurology, National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
6Lysholm Department of Neuroradiology, National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
7Neuro-otology Unit, Department of Brain Sciences, Imperial College London, London, UK
8EvidENT, Ear Institute, University College London, London, UK
Purpose: Imbalance and dizziness are common in classical infratentorial superficial siderosis (iSS). There are few reports characterising vestibular dysfunction in iSS, limited by small cohort sizes. Vestibular dysfunction can arise from involvement of central (from Scarpa’s ganglion proximally, including the vestibulocerebellum and brainstem) or peripheral (distal to Scarpa’s ganglion) structures. We aimed to phenotype vestibular impairment in a large cohort of patients with iSS and localise the site of lesion clinically and radiologically.
Methods: We reviewed records of vestibular assessments of adult patients with confirmed diagnosis of iSS under the care of our multidisciplinary team (June 2004-Sept 2023). We compared the results against age-matched norms and reviewed imaging.
Results: Thirty-one patients (22, 71% males) underwent vestibular assessments (two patients had bedside assessments). The median (IQR) age was 63 (19) years. Central vestibular dysfunction, irrespective of peripheral involvement, was common (74% of patients); 7% of patients had unilateral peripheral vestibular compromise; 10% of patients had no vestibular abnormalities. Oculography (n=29) identified abnormalities involving smooth pursuit (SP) (59%), saccades (45%); horizontal gaze-evoked nystagmus was present in 21% of patients. Bedside assessment in two patients identified no abnormalities of gaze, SP, or saccades. Radiologically, there was invariable involvement of superior vermis and cerebellar folia, followed by frequent involvement of the brainstem.
Conclusions: Central vestibular dysfunction was present in the majority of our cohort, mostly involving the vestibulocerebellum, brainstem or both; these findings have potential implications for the optimal treatment and rehabilitation of iSS. Longitudinal studies are needed to ascertain progression of iSS-related vestibular dysfunction over time.
PPIII:63 - VIDEO HEAD IMPULSE TEST IN SUBACUTE AND CHRONIC STROKE SURVIVORS
Leonardo Manzari1, Nicola Ferri2, Andrea Turolla2, Amaranta Soledad Orejel Bustos3, Laura Casagrande Conti3, Chiara Sorge3, Paolo Pillastrini2, Marco Tramontano4
1MSA ENT ACADEMY Center, Cassino, Italy
2Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
3Santa Lucia Foundation, Scientific Institute for Research and Health Care, Rome, Italy
4Department of Biomedical and Neuromotor Sciences (DIBINEM), Alma Mater University of Bologna, Bologna, Italy
Purpose: The Video Head Impulse Test (vHIT) is a safe and reliable assessment of peripheral vestibular function. Many studies tested its accuracy in clinical settings for differential diagnosis and quantification of the vestibulo-oculomotor reflex (VOR) in various disorders. However, the results of its application after lesions of the CNS are discordant and have never been studied in rehabilitation. This study aims to assess the VOR performance in a sample of stroke survivors.
Methods: This is a cross-sectional study on thirty-six subacute and chronic stroke survivors; only persons with first-ever stroke and able to walk independently, even with supervision, were included. We performed VOR assessments for each semicircular canal by vHIT and balance assessments by the Berg Balance Scale and the MiniBESTest scale
Results: Two hundred and sixteen semicircular canals were assessed using the Head Impuse Impulse paradigm (in both the vertical and horizontal planes), while seventy-two semicircular canals were assessed using the Suppressed Head Impulse paradigm (horizontal plane). There was a high prevalence of participants with dysfunctional canals, particularly for the left anterior and right posterior canals, which were each prevalent in more than one-third of our sample. Furthermore, sixteen persons showed an isolated canal dysfunction. The mean VOR gain for the vertical canals had confidence intervals out of the normal values (0.74- 0.91 right anterior; 0.74- 0.82 right posterior; 0.73-0.87 left anterior).
Conclusions: Our findings suggest that peripheral vestibular function may be impaired in people with stroke, systematic assessment in a rehabilitation setting could allow a more personalized and patient centred approach.
PPIII:64 - Video Head Impulse Test in Wernicke’s Encephalopathy
Pınar Özçelik1, Koray Koçoğlu2, Rahmi Tümay Ala3, Gábor Michael Halmágyi4, Gülden Akdal3
1Bezmialem Vakif University, Department of Neurology, Istanbul, Türkiye
2Dokuz Eylül University Institute of Health Sciences, Department of Neurosciences, Izmir, Türkiye
3Dokuz Eylül University, Department of Neurology, Izmir, Türkiye
4Royal Prince Alfred Hospital, Department of Neurology, Sydney, Australia
Purpose: Wernicke’s encephalopathy (WE) is a metabolic disorder caused by thiamine deficiency and has clinical triad: ataxia, opthalmoplegia, confusion. Treatment of acute WE is a medical emergency. We aim to find out vestibulo-ocular reflex (VOR) impairment in patients with WE.
Methods: We retrospectively evaluated the video head impulse test(v-HIT) results of 4 patients with WE. We obtained demographic, and clinical data from medical records of the WE patients diagnosed between January 2015-December 2018. The v-HIT was performed on 6 semicircular canals(SCCs). Modified Rankin Scale (mRS) was used to determine the disability of WE patients before and after thiamine replacement therapy.
Results: The age of the patients ranged from 20 to 65. One patient had horizontal and vertical conjugate gaze paresis and 3 patients had gaze-evoked nystagmus. Clinical horizontal head impulse test was positive in all patients. The mean VOR gain was 0.59 ± 0.28 in lateral SCCs, 0.82± 0.08 in posterior SCCs and 0.91±0.07 in anterior SCCs. All patients had corrective saccades in lateral SCCs in v-HIT. Mean mRS score was 4.5±1.0 at diagnosis and 2.7 ± 1.3 after thiamine replacement therapy.
Conclusions: Our study confirms that in patients with acute onset ataxia and a central pattern nystagmus, a bilaterally positive, selectively horizontal, clinical head impulse test, especially when confirmed on v- HIT strongly suggests the diagnosis of WE.
7. Clinical Testing for Vestibular Function
Outcome Measures to Monitor and Manage Bilateral Vestibulopathy – A Systematic Review
Michaela de Kock1, Helen Yuan1, Elke Devocht1, Angélica Perez Fornos2, Nils Guinand2, Raymond van de Berg1
1Maastricht University Medical Centre, Mental Health and Neuroscience Research, Maastricht, Netherlands
2Geneva University Hospitals, Department of Clinical Neurosciences, Geneva, Switzerland
Purpose: Bilateral vestibulopathy (BV) is a heterogenous chronic condition that presents with numerous clinical symptoms. Consequently, this results in the heterogeneity of clinical outcome measures. While a consensus for diagnostic criteria exists, agreement is lacking regarding symptom monitoring and management. This systematic review aimed to provide an overview of outcome measures in literature to monitor and manage BV.
Methods: A systematic search of literature was performed in PubMed, Scopus, and Web of Science using the following keywords: bilateral AND (vestibular AND (hypofunction OR failure OR loss OR disorder OR dysfunction) OR vestibulopathy) AND (diagnosis OR outcome OR measure OR assessment). Two independent reviewers screened all articles. Articles that were not reported in English, animal studies, and without open access were excluded.
Results: Over 4,000 articles were retrieved and screened to identify relevant papers. Following analysis, a potential classification system arose to categorize the heterogeneity present within literature. Major categories identified included outcome measures pertaining to objective as well as subjective assessment. Objective measures include reflexive (i.e. video head impulse test to monitor oscillopsia) and functional (i.e. dynamic visual acuity to monitor oscillopsia) assessments. Subjective measures include those pertaining to patient-related outcome measures (i.e. vestibular-specific or general quality of life).
Conclusions: This review highlights the lack of consensus and the need for a structured approach to outcome measure selection. A classification system was proposed, intended to guide an optimal selection of outcome measures to appropriately monitor and manage symptoms in patients with BV.
PPIII:65 - A Pilot Study of Smartphone Eye-Tracking for Detection of Positional Nystagmus
Pouya B Bastani1, Vidith Phillips1, Hector Rieiro1, Shervin Badihian2, Jorge Otero-Millan3, Nathan Farrell1, David Newman-Toker1, Ali Saber Tehrani1
1Johns Hopkins University School of Medicine, Department of Neurology, Baltimore, MD, United States
2Cleveland Clinic, Neurological Institute, Cleveland, OH, United States
3University of California Berkeley, Herbert Wertheim School of Optometry and Vision Science, Berkeley, CA, United States
Purpose: Detecting positional nystagmus is the basis of diagnosing benign paroxysmal positional vertigo (BPPV). Hence, developing methods to streamline the diagnosis will aid in timely patient management and prevent unnecessary ED visits. We sought to examine the accuracy of a smartphone eye-tracking application to quantify eye movements during positional testing and detect positional nystagmus.
Methods: We recruited patients presenting with positional dizziness who were suspected to have BPPV from vestibular rehabilitation clinic, Johns Hopkins Hospital. Our team used a smartphone application developed in-house to record participants’ eye movements while undergoing the Dix-Hallpike and horizontal head roll test. We extracted the eye position data from the application and utilized a MATLAB algorithm to detect traces with nystagmus. An expert reviewed the videos obtained by the phone and marked the ones with nystagmus consistent with BPPV. Finally, we assessed the accuracy of the app against the expert review and calculated its sensitivity, specificity, positive and negative predictive values.
Results: We recruited ten participants (60% women) with an average age of 61.8±15.4. The study team performed a total of 23 positional maneuvers, 4 (17.4%) of which showed nystagmus upon expert review. The phone application results indicated the presence of nystagmus in 3 traces (Sen=75%) and correctly ruled out the presence of nystagmus in 19 traces (Specificity=100%). The positive predictive and negative predictive values of the app were 100% and 95%, respectively.
Conclusions: In this pilot study, we demonstrated that a smartphone eye-tracking application can be used to detect positional nystagmus with high accuracy.
PPIII:67 - American Academy of Audiology Statement on the Assessment of Vestibular Function in the Pediatric Population
Patricia Gaffney1, Violette Lavender2, Katheryn Bachmann2, Melissa Caine3, Michael Castiglione2, Kristen Janky4, Guang Wei Zhou5
1American Academy of Audiology, United States of America
2Cincinnati Children’s Hospital, United States of America
3Children’s Hospital of Philadelphia, United States of America
4Boys Town National Research Hospital, United States of America
5Boston Children’s Hospital, United States of America
Purpose: Advances in pediatric vestibular testing has been considerable in recent years. The Academy assembled experts to create a practical clinical guide to pediatric vestibular function test administration and interpretation for children whose developmental age is young. The guide takes into account variations in practice and available equipment.
Methods: Pediatric vestibular function testing methods were evaluated based on clinical consensus.
Results: The statement offers an overview of vestibular function testing available by age to include an overview of the specific testing process, purpose, expected outcomes, results explanation and interpretation, and practical guidance.
Conclusions: Vestibular function testing is recommended in children with complaints of dizziness and in children with imbalance or delays in gross motor millstones. Even with positive findings in function testing, children may need additional evaluation by other disciplines. Knowledge of additional clinical disciplines would assist in providing additional supports and resources to children and families.
PPIII:68 - ANALYSIS OF THE VIDEO HEAD IMPULSE TEST IN INDIVIDUALS DIAGNOSED WITH VESTIBULAR SCHWANNOMA
Thiago Silva1, Kátia Alvarenga1, Fayez Junior2, Luiza Ferreira2, Djane Santos1
1University of São Paulo, Audiology, Brazil
2University of Brasilia, Otolaryngology, Brazil
Purpose: To analyze video head impulse test (vHIT) gain and vHIT refixation saccades in individuals diagnosed with Vestibular Schwannoma.
Methods: This work was approved by the Brazilian ethics and research committee under number CAAE: 67337123.7.0000.5417. Cross-sectional study comprising 25 individuals (11 men) divided into two groups: G1 - patients without surgery (10 individuals) and G2 - patients with surgery (15 individuals) undergoing vHIT. An analysis of the ocular vestibular reflex (VOR) gain and the characteristics of the refixation saccades (peak velocity, latency and occurrence rate) of the lateral semicircular canals was performed
Results: In G1, 70% showed a normal VOR gain with an average head impulse velocity of 211°/s, while in G2, 100% of the individuals showed changes in VOR gain with an average head impulse velocity of 223.5°/s. Regarding the saccades, G1 presented the mean peak velocity (117.9°/s) and latency (192.8ms) while in G2 the peak velocity (219°/s) and latency (160.1ms). The rate of occurrence of saccades was greater than 85% in both groups
Conclusions: vHIT showed high sensitivity for detecting changes in angular velocity in the lateral canal. The analysis of the refixation saccades is an important parameter for evaluating the vHIT, since 70% of the individuals in G1 presented a normal VOR gain with alteration in the refixation saccades on the side of the lesion. In both groups, the rate of saccades was greater than 85% with peak velocity above 110°/s, compatible with the side of the lesion.
PPIII:69 - AQEM: a Marker of Peripheral Involvement in the Acute Vestibular Diseases
Enrico Armato
1
1University of Padova, Department of Neuroscience, Italy
Purpose: With the term AQEM (Anticompensatory Quick Eye Movements) we define some anticompensatory saccades detected during video Head Impulse Test (vHIT) examination on the healthy side in patients with an acute peripheral vestibular disease (APVD). AQEM can be considered a sign of peripheral involvement in cases of spontaneous nystagmus and can be found in many vHIT tracks, though usually neglected by examiners.
Methods: I retrospectively analyzed 60 vHIT tracks of patients presenting to our attention with acute vertigo.
Results: AQEM occurred in 30 patients (50%). Mean latency was 338.33 ± 24.76 msec. 55% of cases had a history consistent with recent acute rotatory vertigo. 75% of patients presented with horizontal spontaneous nystagmus in hibited by visual fixation and 90% of vHIT documented a specific and isolated impairment of the vestibulo-ocular reflex (VOR) for horizontal canals. AQEM on one side were associated with lower VOR-gain on the contralateral ear (p < 0.0001). 24 patients among 30 cases exhibiting AQEM underwent neuroimaging and none of them showed central nervous system (CNS) pathologies.
Conclusions: Standard profile of AQEM can be summarized as follows. VOR-gain is close to zero for horizontal canal contralateral to the affected side. Typically, there is a spontaneous nystagmus inhibited by visual fixation. Patients mostly present a history of recent acute rotatory vertigo. Mainly horizontal canals are involved. AQEM seem to represent a transient finding. In contrast to few works dealing with this subject, we found very broader and heterogeneous categories of patients, though most of them did not show CNS involvement. AQEM could represent an interesting marker of APVD.
PPIII:70 - Assessment of vertical semicircular canal function with the velocity step test
Erin Williams1, Fumihiro Mochizuki1, Alexander Kiderman2, Michael Hoffer1
1University of Miami Miller School of Medicine, Department of Otolaryngology, Miami FL, USA
2Spryson America, Inc., Pittsburgh, PA, USA
Purpose: Conventional rotational testing involves Earth-vertical axis rotation to assess horizontal semicircular canal (HSCC) function but cannot evaluate the vertical semicircular canals (VSCC). We sought to investigate the relationship between VST and vHIT in all SCCs and to compare per- and post-rotary parameters across three planes: the horizontal plane, the right anterior/left posterior (RALP) plane, and the left anterior/right posterior (LARP) plane.
Methods: Horizontal and vertical vHIT and VST testing was performed in healthy controls (n=24). For VST, participants experienced angular acceleration of 100°/s for 1s then were rotated clockwise or counterclockwise at a constant velocity (100°/s) for 1m before decelerating to 0°/sec for 1s. Time constant (TC) and mean slow-phase peak velocity (MSPEV) were generated for each plane and condition tested during VST. For vHIT, VOR gain was calculated as the ratio of the area under the eye velocity and head velocity curve.
Results: There were no significant left-right differences in the TC observed for any plane in either per or post-rotation. The mean HSCC plane TC (13.8±3.9s/15.1±4.2s [per/post], respectively) was significantly longer than that of VSCC planes (p<0.01). The mean MSPEV in HSCC planes (62.8±13.2/72.2±13.1°/s [per/post] respectively) was significantly longer than in VSCC planes (p<0.01). There was no significant correlation between vHIT-associated VOR gain and MSPEV or TC across all SCCs.
Conclusions: Standard clinical tools including vHIT, caloric testing, and rotational testing complement each other in diagnosing vestibular disorders but may be augmented substantially with a reliable and efficient assessment of the VSCC. Vertical VST is a promising tool for comprehensive vestibular assessment.
PPIII:71 - Bone Conduction VEMPs in Children referred to the Balance clinic
Herra Bhutta1, Anita Won1, Nicola Guderley1, Joseph Schneck1, Nishma Sutaria1, Brindha Anandanadarajah1, Kaukab Rajput1, Waheeda Pagarkar1
1Great Ormond Street Hospital
Purpose: Introduction Vestibular evoked myogenic potentials (VEMP) can be performed with air conduction (AC) and bone conduction (BC) stimuli with AC reflecting saccular and BC, utricular function. BC VEMP is beneficial in conditions such as glue ear and microtia, where AC VEMP is not possible.
Objective: To compare parameters of AC and BC cervical VEMP in children with vestibular symptoms attending Great Ormond Street hospital (GOSH).
Methods: Subjects and Method This is a retrospective case notes review of children with vestibular symptoms, between November 2021 to April 2024. Children who had both AC and BC cervical VEMP were included. Cervical VEMP was conducted using Interacoustics Eclipse system at 500Hz tone bursts. BC VEMP testing used a B81 transducer placed on the mastoid of the side being tested. Testing was standardised. Statistical analyses were performed using SAS version 9.4, with descriptive statistics including mean, median, standard deviation. Comparisons were made using Chi2-tests, paired t-tests and non-parametric Spearman rank tests.
Results: Results Data from 180 children aged between 3 and 17 years was analysed. BC VEMP thresholds were significantly lower than AC VEMP (p<0.001). AC and BC VEMP thresholds, latencies and amplitude were compared. A separate analysis was made for children with cochlear implants. The presence/absence of AC and BC VEMP was correlated with the clinical diagnosis.
Discussion: Results were compared with the existing BC VEMP literature in children.
Conclusions: Conclusion There is significant correlation between AC and BC VEMP parameters. BC VEMP thresholds were lower than AC VEMP thresholds. BC VEMP can be used to assess otolith function, including in conditions where AC VEMP cannot be used.
PPIII:72 - Chronic vestibular syndrome in the elderly: What do the results of the caloric testing indicate?
João Rainha Fernandes1, Andréa Gaspar1, Daniela Serras1, Constança Oom1, João Barbosa1, Carlos Macor1
1Hospital Beatriz Ângelo, Otorhinolaryngology Service, Lisboa, Portugal
Purpose: The main objective was to describe the findings of caloric testing in the elderly with balance disorders.
Methods: We conducted an observational descriptive study of patients ≥ 60 years old, from the vertigo consultation of Hospital Beatriz Ângelo (Lisboa), with chronic vestibular syndrome (balance disorders and/or falls at least 3 months duration), submitted to videonystagmography (VNG), between January 2023 and March 2024.
Results: Of all 268 VNG performed on this time span, we included 176 elderly patients (65,7%), aged between 60 and 91 with an average age of 75. Of them, 136 (77,3%) were female. The caloric testing findings were: 82 patients (46,6%) revealed normal caloric responses with ages between 60 to 90; 42 elderly (23,9%) had bilateral hyporeflexia, aged between 60 and 89; 25 individuals (14,2%) displayed unilateral hyporeflexia, aged between 60 and 91; 12 patients (6,8%) demonstrated a reduced caloric response on one side, without vestibular asymmetry, with ages ranging from 61 and 82; 7 individuals (4,0%) exhibited hyporeflexia with contralateral areflexia (aged between 62 and 84); 5 patients (2,8%) had unilateral areflexia (aged between 67 and 90); 3 elderly (1,7%) presented bilateral areflexia (aged between 72 and 83).
Conclusions: Balance disorders are frequent among the elderly, sometimes mistakenly attributed to the natural aging of the body (presbyvestibulopathy). Looking only at the caloric testing results, we found that most patients had normal caloric responses. With this study we want to show that not all loss of equilibrium is due to the presbyvestibulopathy and that other causes should be investigated.
PPIII:73 - Classifying vestibular disorders based on the video head impulse test – a deep learning approach
Helena Grip1, Anna Diamant2, Johan Skönevik1, Jonatan Salzer2
1Department of Diagnostics and Intervention, Biomedical Engineering and Radiation Physics, Umeå University, Umeå, Sweden
2Department of Clinical Sciences, Neurosciences, Umeå University, Umeå, Sweden
Purpose: The video head impulse test (vHIT) is an important laboratory test for the diagnosis of various peripheral and central vestibular disorders. The aim of this study was to apply deep learning models on vHIT time-series data to discriminate between healthy controls, and subjects with vestibular neuritis or stroke.
Methods: Healthy controls 61 females/26 males, 52±19 years), subjects with vestibular neuritis (13 females/20 males, mean ± SD 63±13 years), and subjects with stroke (25 females/31 males, 68±14 years) underwent vHIT of lateral, if possible, also anterior and posterior, semi-circular canals. The head and eye angular velocity curves were transformed into sets of wavelet-based scalograms, each based of 5 repetitions in randomized order. The retrainable layers of the pretrained deep learning network Resnet101 were replaced and retrained. The data were divided into 10 batches of training, test and validations sets, and each subject were classified once. The simple model used scalograms from lateral impulses only (20 images/subject) and the full model used scalograms from impulses from all semi-cirular canals (365 images/subject).
Results: The simple model discriminated between vestibular neuritis and controls with an accuracy of 94.5±7.8%. All controls were correctly identified, while 12.1% of vestibular neuritis subjects were falsely classified as controls. The full model discriminated between all three groups with an accuracy of 63.1±7.0%. All controls were correctly identified, while 28% of vestibular neuritis were falsely classified as controls and 59.6% of the stroke group were falsely classified as controls.
Conclusions: Classification of vHIT data based could potentially support the discrimination between disorders causing dizziness. A larger training material is needed, especially since stroke subjects have less uniform head/eye velocity curves than controls and subjects with vestibular neuritis.
PPIII:74 - Clinical features and etiology of unilateral isolated and non-isolated posterior semicircular canal dysfunction
Xiang Li1, Kang zhi Li2, Xia Ling3, Yuru Wang1, Yuan Xu1, Jianrong Wang1, Siru Xue1, Xu Yang1
1Peking University Aerospace School of Clinical Medicine (Aerospace Center Hospital), Department of Neurology, China
2Peking University Shougang Hospital, Department of Neurology, China
3Peking University First Hospital, Department of Neurology, China
Purpose: To investigate the clinical characteristics and possible etiology in patients with unilateral posterior semicircular canal dysfunction (UPCD) diagnosed using video head impulse test (vHIT) to enable better clinical diagnosis and treatment.
Methods: Fifty-seven patients diagnosed with UPCD, including 30 patients with isolated UPCD (IPCD) and 27 patients with non-isolated UPCD (NPCD) were enrolled. Baseline clinical data, possible etiologies and results from vHIT were systematically collected.
Results: The incidence of UPCD was 6.7% (57/851), including 3.5% (30/851) for IPCD and 3.2% (27/851) for NPCD. The incidence of the acute vestibular syndrome (AVS) was higher and posterior semicircular gain was lower in the NPCD group than in the IPCD group (P=0.04, P=0.004, respectively). Mean PTA levels were worse in the IPCD group than in the NPCD group (P=0.037,). The most common etiology of IPCD was unilateral peripheral vestibular dysfunction (UPVD) of unclear origin (50%), followed by possible labyrinth ischemia (6/30,20%). The most common etiology of NPCD was possible labyrinth ischemia (10/27,37%), followed by UPVD of unclear origin (8/27,29.6%).
Conclusions: Patients with NPCD more often present with AVS, more severe peripheral vestibular dysfunction, and worse PTA than those with IPCD.
PPIII:75 - Comparison of Electrical Vestibular Stimulation, Caloric irrigation and vHIT as tests of vestibular asymmetry
Peter Gaskell1, Raphael Hamel1, Richard Irving2, Raymond Reynolds1
1University of Birmingham
2University Hospitals Birmingham
Purpose: Electrical vestibular stimulation (EVS) activates the vestibulo-ocular reflex through the transcutaneous delivery of a sinusoidal current across two electrodes. This predominantly evokes torsional eye responses. In two separate studies, we previously showed that EVS compared similarly to both caloric irrigation and vHIT to detect vestibular asymmetry in unilateral vestibular schwannoma (VS). EVS is quicker to perform, has less contraindications, is less operator dependent and more comfortable than both caloric and vHIT.
Our group has received funding to conduct a larger study to directly compare all three tests' (EVS, calorics and vHIT) ability to detect vestibular asymmetry in VS compared to healthy controls (n = 180). We present the pilot data of this ongoing study.
Methods: 10 healthy controls and 3 unilateral VS were tested with EVS, bithermal water caloric irrigation, and lateral vHIT. EVS was delivered unilaterally across electrodes positioned on the mastoid and adjacent to the ipsilateral C7 spine. A 4mA sinusoidal current was delivered at 2Hz to each side to measure asymmetry. Eye responses for all tests were measured with infrared camera-mounted goggles. Asymmetry was assessed using the Jongkees’ formula.
Results: Mean vestibular asymmetry for healthy controls was: EVS: -3.7% [-13.1% to 5.7%], caloric: -6.4% [-13.0% to 0.2%], vHIT: -0.4% [-2.1 to 1.3%].
Mean vestibular asymmetry for unilateral VS was: EVS: -43.8% [-57.2% to -30.4%], caloric: -95.0% [-97.0% to -93%], vHIT: -42.1% [-48.5% to -35.7%].
Conclusions: EVS is comparable to both caloric irrigation and vHIT at assessing vestibular asymmetry in both controls and unilateral VS patients, highlighting its clinical utility.
PPIII:77 - Demographic differences in vestibular evoked myogenic potential tests in symptomatic populations
Jennifer Ren1, Susmita Chennareddy1, Sreekar Miriyala2, Jennifer Kelly3, Maura Cosetti3
1Icahn School of Medicine at Mount Sinai, Department of Otolaryngology-Head & Neck Surgery, New York, USA
2Icahn School of Medicine at Mount Sinai, New York, USA
3Ear Institute of the New York Eye and Ear Infirmary of Mount Sinai, Department of Otolaryngology-Head & Neck Surgery, New York, USA
Purpose: To evaluate the relationship between patient demographics and ocular (oVEMP) and cervical vestibular evoked myogenic potentials (cVEMP) in symptomatic patients.
Methods: We performed a retrospective study of VEMP tests performed on symptomatically dizzy patients at our academic tertiary care clinic from 2022-2023. Demographic patient characteristics were collected, and VEMP testing was considered abnormal if there was either no response or an asymmetry ratio >33% or >47% for oVEMP and cVEMP, respectively. P-values and odds ratios were calculated with logistic regression.
Results: There were 146 500 hertz (Hz) VEMP tests in 143 patients (144 oVEMP, 146 cVEMP). 16.7% of oVEMP and 13.7% of cVEMP scores had no response unilaterally and 27.1% of oVEMP and 4.1% or cVEMP scores had no response bilaterally. 50.1% of oVEMP and 24.7% of cVEMP tests were abnormal. Compared to ages <50, ages 60-69 and 70-79 were significantly more likely to have abnormal oVEMP tests (OR 4.33, 9.53; p = 0.03, 0.04), and ages 70-79 were significantly more likely to have abnormal cVEMP tests (OR 19.33, p = 0.01). Partnered individuals were significantly less likely to have abnormal oVEMP (OR 0.17, p=0.001) and cVEMP (OR 0.16, p = 0.01) tests. Other demographic characteristics, including race and insurance status, were not significantly associated with VEMP outcomes.
Conclusions: Our findings corroborate age-related VEMP changes from previous literature. In contrast to studies demonstrating racial differences in VEMP outcomes in asymptomatic patients, we did not find racial differences in symptomatically dizzy patients.
PPIII:78 - Detecting low-frequency of different combinations of semicircular canals for diagnosing acute unilateral vestibulopathy
Xiaobang Huang1, Xueqing Zhang1, Taisheng Chen1, Wei Wang1, Qiaomei Deng1, Chao Wen1
1Tianjin First Central Hospital, Department of Otorhinolaryngology Head and Neck Surgery, China
Purpose: To investigate the characteristics of low-frequency induced nystagmus in different combinations of semicircular canals in acute unilateral vestibulopathy(AUVP) and their localization value in the diagnosis of AUVP.
Methods: Twenty-two patients with AUVP and 52 healthy volunteers were recorded nystagmus induced with different combinations of semicircular canals by 3D-VNG, and the left and right lateral semicircular canals were stimulated by turning the head left and right in the Yaw plane at 0.3Hz and ±45° amplitude, the anterior semicircular canals and the posterior semicircular canals were stimulated in the Pitch plane, and the anterior+ posterior semicircular canals on each side were stimulated by rolling the head left and right in the Roll plane. The SPV and its asymmetric indexes of induced nystagmus were analyzed, and the differences of induced nystagmus indexes of different combinations of semicircular canals between the two groups were analyzed.
Results: Induced nystagmus of two groups are the same direction with that of head movement in three planes. There are statistically significant difference between the SPVs of horizontal nystagmus of the affected and unaffected sides, the affected side and the control group in the Yaw plane, and vertically up and down nystagmus in Pitch plane. But there is no significant difference between the SPVs of twisting nystagmus induced in the Roll plane. There was statistically significant difference in the SPV asymmetry between the AUVP group and the control group(P<0.05).
Conclusions: The low-frequency induced nystagmus in patients with AUVP in different combinations of semicircular canals presents different horizontal, vertical and torsional nystagmus directions and SPV characteristics, and the low-frequency detection of different combinations of semicircular canals can provide an objective basis for the localized diagnosis of the semicircular canals(especially the vertical semicircular canals) of AUVP.
PPIII:79 - Discrepancy in the results of the semicircular canal function test: vHIT vs. Caloric Test
Taro Inagaki1, Kinuho Machii1, Teruhisa Yano1, Noriko Nagai1, Yasuo Ogawa1, Kiyoaki Tsukahara1
1Tokyo Medical University, Department of Otorhinolaryngology Head and Neck Surgery, Japan
Purpose: The video head impulse test (vHIT) enables the quantitative evaluation of each semicircular canal function individually. Caloric test has been used worldwide for many years as a standard test for lateral semicircular canal function. In clinical, these 2 test results sometimes differ. The aim of this study is to investigate what makes these test results discrepant.
Methods: The patients were diagnosed with canal paresis (CP) when the VOR gain < 0.8 with catch up saccade (CUS) in the lateral semicircular canal in vHIT, and CP%≧20 in caloric test using an air caloric device.
Results: Both tests were performed in 36 patients diagnosed with unilateral peripheral vestibular dysfunction. In patients with unilateral peripheral vestibular dysfunction, there was a correlation between the VOR gain in vHIT and the maximum slow phase velocity (MSPV) in caloric test. On the other hand, in 14 cases, there were discrepancies between the results of these tests. Of the 14 cases, 8 were associated with endolymphatic hydrops, consisted of 6 of 9 Meniere's disease(MD) cases and 2 of 2 delayed endolymphatic hydrops(DEH) cases.
Conclusions: vHIT and caloric tests are both semicircular canal function tests, but the stimulation methods and diagnostic methods are different. Although there was a correlation and no significant discrepancy in the test results between them, it had better use these tests complementarily especially in the cases associated with endolymphatic hydrops.
PPIII:80 - Does Adjusting for Head Position Matter in Fundus Photography?
David Hale1, Dipakshi Tare2, Kemar Green1, Amir Kheradmand1
1Johns Hopkins School of Medicine, Department of Neurology, United States
2Universita della Svizzera italiana, Switzerland
Purpose: Ocular torsion can be evaluated by the disc foveal angle (DFA) on fundus photos. In fundus photography, head position is not controlled for even though it can affect ocular torsion through the vestibulo-ocular response known as the ocular counter-roll. We examined the position of the head and how it may affect measurement of ocular torsion during fundus photography.
Methods: Fundus photos were taken of 10 participants. The head position was measured using a gyroscope attached to the head. Three photos were taken of each eye in a standard condition with the head on a chin rest without adjustment. For comparison, three photos were taken from each eye (i) with the head on the chin rest adjusted upright and (ii) with the head on the chin rest and tilted 10° to the left and right. The DFA was measured and compared between the three conditions.
Results: There was a larger head tilt angle in the standard condition compared to when the head position was adjusted upright (Standard 1.31°±0.09°; Upright 0.07°±0.01°; p<0.0001). However, there was no significant difference in DFA between the standard and upright conditions (Standard OD=4.41°±0.79°, OS=5.56°±0.68°; Upright OD=4.27°±0.94°, OS=5.24°±0.77°; p=0.62). There was a significant difference in DFA when the head was tilted 10° compared to the upright position (p<0.0001).
Conclusions: The positioning of the head during fundus photography can affect DFA measurement. While large head tilts can cause change in DFA measurement, the standard head position with the head upright on the chin rest does not have a significant effect.
PPIII:81 - Effect of head position on cervical vestibular evoked myogenic potential
Arata Kemmochi1, Toru Seo2, Mizuho Aomi2, Yasuhiro Miyamoto1, Izumi Koizuka3, Manabu Komori3
1Kanbara Public Hospital, Department of Otolaryngology-Head and Neck Surgery, Japan
2St. Marianna University Yokohama Seibu Hospital, Department of Otolaryngology-Head and Neck Surgery,Japan
3St. Marianna University Hospital, Department of Otolaryngology-Head and Neck Surgery, Japan
Purpose: Cervical vestibular evoked myogenic potential (cVEMP) reflects the function of the saccular organ. Since the saccule is placed approximately in the sagittal plane, there may be an impact between the stimulation-ear-up (S-up) position and stimulation-ear-down (S-down) position, as the direction of gravity on the macula reverses. The purpose of this study was to clarify the influence of head position on cVEMP.
Methods: Six healthy adults without a history of otological or neurotological disorders participated. We measured cVEMP in both S-up and S-down positions using air-conducted sound (ACS) and bone-conducted vibration (BCV).
Results: The amplitude of cVEMP to ACS at the S-down position decreased by 4.6% compared to that of the S-up position. There was no difference in the amplitude of cVEMP to BCV between the two positions. There were no differences in the latency of p13 and n23 between head positions for either stimulus type.
Conclusions: Head position influenced the amplitude of cVEMP to ACS but not BCV. This is likely due to differences in stimulus transmission. With ACS, vibrations of the saccular membrane are efficiently transmitted to the sensory cells in the S-up position, as the mass of otoconia is located above the sensory hair cells, whereas this efficiency decreases in the S-down position due to detachment of the otoconia from hair cells. With BCV, the hair cells are directly vibrated by the saccular macula, so head position is not considered to affect the transmission to hair cells.
PPIII:82 - Effects of middle ear pressure changes on cervical vestibular-evoked myogenic potentials
Maja Brumm1, Irene Chung1, Mehrdad Aghamohammadi2, Peter Thorne1, Rachael Taylor3
1University of Auckland, Section of Audiology, New Zealand
2University of Auckland, Department of Engineering, New Zealand
3University of Auckland, Department of Physiology, New Zealand
Purpose: Cervical vestibular-evoked myogenic potentials (cVEMPs) are commonly recorded using air conducted (AC) sound. Responses can therefore be absent in people with middle ear pathology and conductive hearing loss. However, the effects of changes in middle ear pressure (MEP), which can occur without significant loss of hearing, have not been systematically studied.
Methods: Using a novel approach, the MEP of 11 participants was systematically manipulated with continuous positive airway pressure. Amplitudes and rates of cVEMP detection were recorded at four MEP levels (baseline_±49, +50-99, +100-149 and >150 daPa, assessed by tympanometry) in response to air- and bone-conducted (BC) stimulation at 500, 1000 and 2000 Hz. Puretone audiometry was undertaken to evaluate effects on hearing.
Results: Air-conducted cVEMP amplitudes decreased steadily with increasing middle ear pressure (p<0.001). The effect was greatest for the 500 Hz stimulus, revealing a 52.2% decline in amplitudes by the highest MEP condition (>150 daPa). The MEP also affected 500 Hz AC hearing thresholds, but only at the highest level, and none of the participants with abnormal 500 Hz AC cVEMPs had significant air-bone gaps on audiometry. BC cVEMP amplitudes were unaffected by MEP until >150 daPa where 500 Hz amplitudes increased slightly.
Conclusions: Air-conducted cVEMP amplitudes can be affected by relatively small changes in middle ear pressure. To avoid errors in VEMP interpretation, we recommend undertaking tympanometry when using an AC stimulus.
PPIII:83 - Evaluation of semicircular canal and otolith graviceptive pathway function in patients with motion sickness disorder
Ning Song1, Yuexia Wu1, Yue Xing1, Tongtong Zhao1, Qianqian Wang1, Xinyan Ma1, Kangzhi Li2, Xu Yang1
1Peking University Aerospace School of Clinical Medicine (Aerospace Center Hospital), Department of Neurology, China
2Peking University Shougang Hospital, Department of Neurology, China
Purpose: To investigate the altered function of the canal and otolith graviceptive pathway in patients diagnosed with motion sickness disorder (MSD).
Methods: Twenty patients with MSD and age- and sex-matched healthy controls were recruited between March and August 2022. All participants completed the MSSQ-short version and the motion sickness assessment questionnaire (MSAQ). Canal function was evaluated using caloric stimulation test and vHIT. SVV/SVH and VEMP were employed to assess otolith graviceptive function. Differences in vestibular function and correlations between the two groups were analyzed.
Results: The scores of MSSQ-short [27.0 (22.5, 38.8) vs 1.2 (0, 3.2), P<0.001] and MSAQ [70.1 (54.5, 78.1) vs 11.8 (11.1, 13.9), P<0.001] were significantly higher in the MSD group. A significantly higher incidence of caloric stimulation intolerance in MSD patients (60.0%, 12/20) was revealed compared with that of the control group (20.0%, 4/20) (P=0.010). No significant difference was found in SVV, SVH and cVEMP between two groups (all P>0.05). The oVEMP abnormality rate was significantly higher in the MSD group (55.0%, 11/20) than that of the control group (10.0%, 2/20) (P=0.002), with a delayed P1-wave latency compared with the control group [(18.4±1.2) ms vs (17.6±0.8) ms, P=0.018]. Correlation analysis revealed that P1-wave latency in oVEMP was positively correlated with MSSQ-short(r=0.486, P=0.002), MSAQ scores (r=0.391, P=0.015), and duration of caloric intolerance symptoms (r=0.377, P=0.004).
Conclusions: The presence of hypersensitivity to caloric stimulation and delayed latency of otolith function in MSD suggests a “separation” between semicircular canal and otolithic function, which may be related to sensory conflict.
PPIII:84 - Evaluation of subjective visual vertical and horizontal in patients with acoustic neuroma based on virtual reality
Xiaowu Tang
1
1Department of Otolaryngology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University
Purpose: To investigate potential differences in absolute deviation values of subjective visual vertical and horizontal between unilateral acoustic neuroma patients and healthy young adults under varying degrees of static head tilt, with the aim of determining the effect of acoustic neuroma on gravity sensory pathway function in patients.
Methods: We recruited 22 patients diagnosed with unilateral acoustic neuroma and 25 healthy young adults and employed virtual reality technology to assess the absolute deviation values of subjective visual vertical (SVV) and subjective visual horizontal (SVH) under eight different static tilted head positions (Head centered (0° tilt), PdP, Head tilt 15°, 30°, 45° to the left and right), then compare and analyze intergroup differences.
Results: In the Head-centered position, both SVV and SVH absolute deviated values were significantly higher in the AN group compared to healthy young adults. The AN group exhibited significantly higher absolute deviation values of SVV compared to the healthy group when tilting their head 30° left and right. Additionally, when tilting their heads to the right at 15° and 45° the AN group showed significant increases in SVH absolute deviated values compared to healthy adults. The SVV and SVH absolute deviation values of LAN and SAN groups did not reach statistical significance. The results of the SVV test for PDP position did not show any significant differences among all groups. However, the SVH test revealed that the absolute deviation values of the LAN group were significantly higher than that of healthy individuals.
Conclusions: Our study shows that the gravity sensing function of patients with unilateral acoustic neuroma is affected to different degrees, when acoustic neuroma is larger than 2 cm, the effect of proprioception on patients’ SVH outcome is noteworthy. So,we should pay attention to the postoperative follow-up of patients with acoustic neuroma and the evaluation of vestibular rehabilitation effect.
PPIII:85 - Frequency dependence of human thresholds – perceptual and vestibulo-ocular reflex (VOR) thresholds
Takamori Takeda1, Junichi Tajino1, Takeshi Tsutsumi2, Daniel Merfeld1
1The Ohio State University, Otolaryngology, USA
2Tokyo Medical and Dental University, Otolaryngology, Japan
Purpose: While perceptual thresholds have been widely studied, VOR thresholds have received less attention. Therefore, the relationship between VOR and perceptual thresholds still remains unclear. Our goals are to measure the frequency dependence of human VOR thresholds, to compare VOR thresholds with human perceptual thresholds, and to investigate the impact of gravity on both VOR and perceptual thresholds.
Methods: Perceptual thresholds were measured in 8 subjects at 4 frequencies (0.2, 0.5, 1 and 2Hz) using a forced choice task with motion provided by a Moog 6DOF motion platform. For subsequent VOR threshold trials, 6 of these same subjects wore a video-oculography EyeSeeCam Sci system (500 Hz). A comparison between psychometric (perceptual) and oculometric (VOR) width parameter (i.e. threshold) was performed to quantify each as a function of frequency.
Results: VOR thresholds were relatively constant across our 4 frequencies and generally a little smaller than perceptual thresholds both for yaw rotation about an earth-vertical axis and yaw tilt (yaw rotation about an earth-horizontal axis). Perceptual thresholds for both yaw tilt and yaw rotation were constant at 0.5 Hz and higher. For yaw tilt, perceptual thresholds decreased at 0.2 Hz, while, for yaw rotation, thresholds increased at 0.2Hz.
Conclusions: We conclude: (i) that the known contributions of velocity storage to the VOR likely yielded VOR thresholds that were similar for yaw rotation and yaw tilt for all frequencies tested, and (ii) that the integration of otolith and horizontal canal signals during yaw tilt when supine contributes to stable perceptual thresholds at lower frequencies.
PPIII:86 - Influence of different bone conduction transducers in oVEMP Testing
Bo Håkansson1, Karl-Johan Fredén Jansson1, Ian Curthoys2, Leigh McGarvie3, Luca Verrecchia4, Zheer Tawfique4, Laura Fröhlich5, Julia Dlugaiczyk6, Torsten Rahne7, Måns Eeg-Olofsson8, Sabine Reinfeldt1
1Department of Electrical Engineering, Chalmers University of Technology, Gothenburg, Sweden
2Vestibular Research Laboratory, School of Psychology, Faculty of Science, University of Sydney, Sydney, NSW, Australia
3Neurology Department, Institute of Clinical Neurosciences, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
4Karolinska University Hospital, · Department of Audiology and Neurotology, Stockholm, Sweden
5Department of Otorhinolaryngology, University Hospital Bonn, Bonn, Germany
6Department of Otorhinolaryngology, Head and Neck Surgery & Interdisciplinary Center of Vertigo, University Hospital Zurich (USZ), University of Zurich (UZH), Switzerland
7University Medicine Halle, Dept. of Otorhinolaryngology, Halle (Saale), Germany
8Department of Otolaryngology, Head and Neck Surgery, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
Purpose: Air conduction (AC) stimuli for ocular vestibular evoked myogenic potentials (oVEMP) require high sound levels and are limited to patients without conductive hearing losses. By using bone conduction (BC) stimuli these drawbacks can be avoided.
The B250 is a new BC transducer of variable reluctance type, which is smaller and easier to use than the present Minishaker B&K4810 which is of moving coil type. We measured the mechanical output of the Minishaker and the B250 to detect differences in the mechanical stimuli and differences in the oVEMP responses.
Methods: The mechanical stimuli were delivered by the BC transducers located on the forehead midline/hairline (Fz) and measured using Laser Doppler Vibrometry (LDV) pointing at the skin over the mastoid. Subsequent oVEMP responses were recorded in the same setting and in the same subjects. A single sine wave at 250 Hz (0-1-0) was used in both condensation and rarefaction modes.
Results: Both the Minishaker and the B250 were found to generate consistent oVEMP responses but for the B250, n10 latencies were delayed on average 2 ms with condensation stimuli. LDV measurements showed that the first peak in both condensation and rarefaction modes with the B250 had lower magnitude than the second peak which may explain the delay in the oVEMP n10 latencies.
Conclusions: LDV and oVEMP results suggest that the B250 can replace the Minishaker B&K4810. Differences found in n10 latencies do not affect the clinical interpretation since both left/right oVEMP responses are equally delayed and are related to the mechanical design of the B250.
PPIII:87 - Measurement of Amplitude-Modulated cervical Vestibular Evoked Myogenic Potentials (AMcVEMP) with Auditory Stimuli
MIZUHO AOMI1, TORU SEO1, IZUMI KOIZUKA2, MANABU KOMORI2
1Department of Otolaryngology-Head and Neck Surgery, St. Marianna University Yokohama Seibu Hospital, JAPAN
2Department of Otolaryngology, St. Marianna University School of Medicine, JAPAN
Purpose: Cervical vestibular evoked myogenic potentials (cVEMP) are muscle-originated responses recorded from the sternocleidomastoid muscle in response to sound stimulation, uniquely originating from the saccule of the vestibular organ. We have previously explored the frequency response of cVEMP and its clinical applications. Recently, amplitude-modulated (AM) sound stimulation-induced cVEMP (AMcVEMP) has been reported, and the clinical applications are expected. This study aimed to determine whether AMcVEMP could be recorded at our facility.
Methods: The subjects were 6 healthy adults with no history of otologic or neurotologic disorders. The stimulus used was amplitude-modulated sound with a carrier frequency of 500Hz and modulation frequencies of 23Hz, 37Hz, 113Hz, and 211Hz. The measurement conditions were the same as those for conventional cVEMP at our institute. The sound stimulations were provided through earphones on a side with turning their head to the opposite side for keeping tonus of the sternocleidomastoid muscle on the same side.
Results: Responses following the stimuli were recorded under all conditions. The amplitude of these responses was greater with a modulation of 37Hz than with other modulations. This confirms previous reports that the amplitude peaks around a modulation frequency of 40Hz.
Conclusions: AMcVEMP could be recorded at our facility. We will investigate the clinical applications.
PPIII:89 - Performing electrical vestibular stimulation (EVS) to robustly assess interaural vestibular asymmetry
Raphael Hamel1, Peter Gaskell2, Richard Irving2, Raymond Reynolds1
1School of Sport, Exercise, and Rehabilitation sciences, University of Birmingham (UK)
2Queen Elizabeth Hospital, Birmingham (UK)
Purpose: Electrical vestibular stimulation (EVS) consists of delivering a transcutaneous sinusoidal current through a pair of electrodes to activate the vestibulo-ocular reflex, evoking mainly torsional eye responses. Interestingly, previous work from our laboratory showed that EVS performs as well as caloric irrigation to detect interaural vestibular asymmetry in vestibular schwannoma patients whilst being a faster and more comfortable alternative. Given the potential clinical utility of EVS, the overarching objective of this work was to provide clinical guidelines as to how to robustly assess interaural asymmetry using EVS.
Methods: Here, in a young healthy population (n = 72), a 40sec-long sinusoidal current at 0.5Hz was delivered unilaterally between a stimulating and reference electrode positioned on the mastoid process and next to the C7 spinous process, respectively. To assess interaural asymmetry, translational and torsional eye responses were non-invasively recorded using commercially available cameras tracking the pupil and iris. A series of experiments manipulated the current intensity (2 vs 4mA), presence or absence of ambient (and fixation) lights, location of the reference electrodes, sinusoidal current frequency (0.5 vs 2Hz vs a combination of both frequencies), and stimulation duration (10 vs 20 vs 30 vs 40 sec).
Results: The results showed that as long as at least 20sec of torsional eye responses are recorded – regardless of all other manipulated parameters – interaural asymmetry consistently averaged at ∼0% and ranged between ±25%, which is a value in line with population data from caloric irrigation.
Conclusions: Overall, this shows that EVS can robustly assess interaural vestibular asymmetry in a wide variety of testing conditions.
PPIII:90 - Reconsidering the origin of cervical vestibular evoked myogenic potentials
Jonas Bruun Kjærsgaard1, Dan Dupont Hougaard1, Herman Kingma1
1Department of Otorhinolaryngology, Head & Neck Surgery and Audiology, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
Purpose: To investigate the validity of cervical vestibular myogenic potentials(cVEMP) as a measurement of saccular function.
Background: More than thirty years ago, cVEMPs were discovered in humans in response to high intensity sound stimulation. Early animal studies provided, for the time, convincing evidence that cVEMPs were predominantly of saccular origin. This led to the widely advocated clinical implementation of cVEMPs as a measurement of saccular and inferior vestibular nerve function. This exclusivity of the saccule as the prime determinant for cVEMP responses were challenged by animal studies in the late noughties, as these discovered a substantial co-activation of the utricle. In the latest animal studies relevant co-activation of the semicircular canals is even present. Despite of this, cVEMP remains to be used by many clinicians as a measurement of saccular function, supported by the perpetually advocated saccular predominance theory, which presents this as a scientific fact beyond discussion. This is peculiar as the theory itself was seriously criticized and debated by many esteemed scientists. To our knowledge, there are still no conclusive clinical studies showing that saccular function, or inferior vestibular nerve integrity is a necessity for cVEMPs to be generated.
Methods: A scoping review of the literature on basic vestibular physiology, translational vestibular research and clinical vestibular medicine in the frame of exhaustively understanding cVEMP.
Results: We find that the dispute is still unsettled and needs to be revisited. In our presentation we will bridge the original findings of Goldberg and Uchino with a collection of animal studies examining the acoustic responsivity of vestibular afferents.
Conclusions: We conclude that the saccular predominance theory in its present form cannot explain the crossing cVEMP and lacks a basic scientific proof behind a key element of the theory. Following, there is insufficient evidence to support cVEMP-usage as a specific clinical test of saccular function.
PPIII:91 - Relationship between results of objective vestibular tests (VNG) and basic hearing tests (BA) for diagnostic testing
Helen S Cohen1, Haleh Sangi-Haghpeykar1, Nathan Silver1, Liam D Ferreira1, Jen Li Dong1, Alex D Sweeney1
1Baylor College of Medicine
Purpose: When patients complain of symptoms which might be consistent with vestibular disorders, physicians often order hearing tests, but only sometimes order VNGs. This practice habit might not give physicians good information with which to determine diagnoses. Because unnecessary testing is expensive and onerous, we sought to determine if testing with only the BA results were useful for determining the VNG results.
Methods: This retrospective study screened the electronic medical records of 651 patients seen at our tertiary care center between 2015 and 2021 upon referral by physicians from our institution. All patients had had a VNG and a BA. VNG subtests: cervical vestibular evoked myogenic potentials, Dix-Hallpike maneuvers and bi-thermal caloric tests with either air or water. BA subtests: pure tone averages, tympanogram, word recognition. For the purposes of this study, all subtests were scored as normal/ abnormal.
Results: The final sample included 401 females, 250 males, mean age 57 yrs, (±15, range 21 to 92). More patients had abnormal BA scores than VNG scores. Age was significantly related to abnormal scores. Sex was not related. Overall, abnormal BA and abnormal VNG scores were related, but pure tone averages and tympanogram scores were not related to VNG subtests. Abnormal word recognition combining both ears was related to normal and abnormal bi-thermal caloric tests.
Conclusions: If you merely need to know whether or not the patient might have an abnormal vestibular response, then performing a BA might be adequate. If, however, you need data to determine a definitive diagnosis, then you should order a VNG.
PPIII:92 - Stapes Surgery, postoperative vestibular function in our center
Zenaida Piñeiro Aguín1, Aida Fernández Lebrero1, Roser Boza Gómez1, Gabriel Pedemonte Sarrias1
1Hospital del Mar Barcelona
Purpose: Middle Ear surgery including stapedotomy are surgical procedures involving middle ear and sometimes, vestibular function can be damaged. This study aims to provide a comprehensive review of the most important causes of vertigo associated with surgery with the goal of minimizing the incidence of this complication. Understanding the underlying factors contributing to vertigo in this context is crucial for the prevention and effective management of vertigo in patients undergoing stapedotomy and other middle ear procedures.
Methods: A single-center prospective observational study included all patients undergoing otologic surgery between January 2021 and December 2023 in a university hospital center. 163 patients were scheduled for surgery: 71 for otosclerosis, 44 for tympanoplasty with or without ossiculoplasty, 41 for cholesteatoma and 8 for other procedures.
Vestibular study were performed before and 1-day, 1-week and 3 months after surgery with VHIT (video head impulse test). Perioperative dizziness was determined using a DHI questionnaire.
Etiologies were determined by analyzing the symptoms in combination with changes in objective vestibular function. Patients with pathological VHIT and dizziness were refered to vestibular rehabilitation.
Results: Before surgery, vestibular function was normal in 161 cases (98 %), unilaterally hypofunctional in 1 (0.49 %), and bilaterally hypofunctional in 1 (0.49 %). 12 cases (7.3 %) reported dizziness before surgery. A total of 17 cases (10.4 %) experienced postoperative dizziness. Ten patients experienced immediate transient dizziness (including 1 case of postoperative laberintization); six experienced immediate prolonged dizziness and one experienced recurrent episodic dizziness (VPPB).
Only 5 cases of 17 that experienced vertigo had pathological results in VHIT.
Conclusions: Vertigo after middle ear surgery is not so frequent.
Understanding the underlying factors contributing to vertigo is crucial for the prevention and effective management of vertigo in patients undergoing middle ear procedures.
VHIT only can not explain all clinics.
We need more studies for understand causes and prevent this complication.
PPIII:93 - Study of the refixation saccades using vHIT in patients with balance disorders
Pablo Melgarejo-Moreno1, Mariela Andrea Carboni-Muñoz1, Montserrat Borras-Perera1, Victor Palomar-Asenjo2, Xavier Galindo-Ortego1
1Santa Maria Universitary Hospital of Lleida, Spain
2Arnau Vilanova Universitary Hospital of Lleida, Spain
Purpose: To determine the frequency and type of refixation saccades present in patients with balance disorders. The video head impulse test allows to analyse independently each of the six semicircular canals of the inner ear, as well as to establish objective gain values of the vestibulo-ocular reflex and to know the presence of overt and covert refixation saccades, establishing greater diagnostic accuracy.
Methods: An observational, longitudinal, cross-sectional, and retrospective study of anonymised data of 56 subjects aged between 15 and 90 years with balance disorders was carried out. It was carried out using the video head impulse test performed in the Otoneurology unit of the Departament of Otorhinolaryngology of the Santa Maria university Hospital of Lleida during the month of July 2021.
Results: Of the 56 study subjects, 31 cases (55.4%) were female and 25 cases (44.5%) were male with a predominant age range between 60 and 74 years (39.3%). Among the eight subjects with refixation saccades, the majority present chronic syndromes there are 2 cases (25%) with persistent perceptual postural dizziness (PPPD) and 3 cases (37.5%) with posterior fossa tumors ( a neuroma of the VIII nerve, an intracanalicular lipoma and a schwannoma of the vestibular nerve). Overt saccades were more prevalent and affected the posterior semicircular canal in 50% of cases.
Conclusions: In our study refixation saccades are fundamentally present in pathologies that are included in chronic vestibular syndromes and that there is a correlation between the presence of refixation saccades with the age of patients. The overt saccade type was the most frequent and mostly affected the posterior semicircular canal. No correlation could be proved with the gender of the subjects.
PPIII:94 - Subjective Visual Vertical Revisited: Relevance of testing in various vestibular disorders
Chetana Naik
1
1Ear Nose Throat & Vertigo Clinic, Consultant Neurotologist, India
Purpose: Subjective Visual Vertical assesses the ability to perceive verticality which depends on visual, vestibular and somato sensory inputs. The judgement of verticality is altered when there is otolith dysfunction. The purpose of this study is to assess and analyse S.V.V. in various vestibular disorders we encounter in our vertigo clinic.
Methods: Total of 500 subjects presenting with peripheral vestibular disorders in a period of 4 years from Jan 2020 to Dec 2023 were selected. They had been subjected to neurotological history taking and examination. Subjects with non vestibular causes were excluded. S.V.V. was tested by clinical Bucket test as well as by the VNG machine. The angle of deviation from vertical in degress was noted and the average after repeated stipulated trials was taken. Normal deviation is considered 0+/- 2 degree. We have also analysed its relevance in vestibular compensation and prognosis.
Results: 82% of subjects diagnosed with Vestibular Neuritis, 55 % of those with confirmed Meniers Disease, 77% with treated BPPV and 15 % with other causes including vestibular paroxysmia showed abnormal deviation in Subjective Visual Vertical.
Conclusions: Subjective Visual Vertical is a reliable screening tool in assessment of vestibular function along with other tests. It has a prognostic value during recovery following vestibular damage.
PPIII:95 - TeleAutoHINTS: A Semi-Autonomous AR or VR-Based System for Remote Vestibular and Eye Movement Assessment
Jonathan Browne1, Haochen Wei2, Justin Bosley1, Preetham Bachina3, Edward Kuwera4, Peter Kazanzides2, Kemar Green1
1Johns Hopkins University, Department of Neurology
2Johns Hopkins University, Laboratory for Computational Sensing and Robotics
3Johns Hopkins University School of Medicine
4Johns Hopkins University, Department of Ophthalmology
Purpose: Several million patients in the United States visit the emergency room (ER) annually with symptoms of vertigo or dizziness. Rapidly distinguishing between benign causes, such as inner ear disease, and more severe conditions, like strokes, necessitates performing and interpreting a three-step bedside head and eye movement assessment called HINTS (head impulse, nystagmus, and test of skew). A significant barrier to its widespread adoption of the the HINTS is the shortage of experts trained to safely perform and interpret this test in the ER. This highlights the need for automated remote assessments. In response, we developed TeleAutoHINTS as a two-part solution: (1) a head-mounted display-based head and eye tracking platform, using Microsoft Hololens2, for automated tele-sensing and (2) an interconnected interface for real-time data visualization and analysis.
Methods: The TeleAutoHINTS system comprises two parts: the head-mounted display-based testing platform referring as Patient Testing Interface (PTI), which designed to guide patients through the test, and the desktop visualization and validation platform referring as Medical Provider Interface (MPI). The MPI allows providers to switch between automatic data collection (patient-initiated) and quasi-automatic data collection (provider-initiated). It also offers an interface for real-time monitoring and post-test data analysis. Both interfaces were created using Unity3D (version 2021.3.28f1).
Results: The TeleAutoHINTS test results from all three subjects demonstrate that the system can produce high-quality head and eye traces that mimic physiologic eye movement responses to head impulses with the appropriate amplitude, velocity, and duration. The head velocity data from the head-impulse exceeds 120 degrees per second for all subjects, aligning with clinical standards.The simulated nystagmus waveforms are robust, closely resembling the typical jerk nystagmus waveform morphology.
Conclusions: We have demonstrated that it is feasible to automatically collect components of the HINTS using our AR/VR-powered TeleAutoHINTS system.
PPIII:96 - The effect of enhanced vestibular function in SCD and vestibular migraine on the late peaks of the oVEMP
Alyssa Dyball1, Belinda Kwok1, Rachael Taylor1, Konrad Weber2, Miriam Welgampola3, Sally Rosengren3
1Central Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
2Departments of Neurology and Ophthalmology, University Hospital, Zurich
3Neurology Department and Institute of Clinical Neurosciences, Royal Prince Alfred Hospital, Camperdown, Australia
Purpose: Following the oVEMP n10 peak, multiple peaks can be elicited. The initial peaks follow a dominant contralateral pathway, while smaller, later peaks are elicited bilaterally. In this study we investigated the effect of enhanced vestibular function on these late peaks by comparing patients with superior canal dehiscence (SCD) and vestibular migraine (VM) to healthy volunteers.
Methods: oVEMPs were elicited to air conduction (AC) click stimuli in 40 patients with unilateral SCD, 20 patients with VM with enlarged n10 amplitudes unilaterally, 25 patients with VM with normal n10 amplitudes, and 49 healthy volunteers.
Results: AC sound elicited up to four peaks in patients with SCD and healthy volunteers, and up to 6 peaks in patients with VM. Stimulating an ear with SCD produced enlarged early and late peaks in both eyes, though larger on the contralateral side. The n10 contralateral peak was around 9 times larger than normal but the degree of enlargement decreased as the waves progressed. A similar trend was observed in patients with VM and enlarged amplitudes, however here the contralateral n10 peak was only approximately 3 times as large as healthy volunteers. In patients with VM and SCD, any ears with non-enlarged n10 amplitudes showed similar late responses to healthy volunteers.
Conclusions: SCD increased the amplitude of the oVEMP, particularly for the first two peaks. VM increased the amplitude to a lesser degree, and in some patients prolonged the response. This study provides evidence for a central generator for some of the late oVEMP peaks.
PPIII:97 - The Impact of Stapes Surgery on Vestibular Function and Dizziness - A Pilot Before-and-After Study
Miguel Campos Lopes1, Vera Miranda1, Luciana Rodrigues1, Alexandra Correia1, Hélder Silva1, Natália Oliveira1, Diana Ribeiro1, Vanessa Neves1, Paulo Gonçalves1
1Department of Otorhinolaryngology, Unidade Local de Saúde de Entre o Douro e Vouga, Santa Maria da Feira, Portugal
Purpose: Stapes surgery is a commonly performed procedure in otosclerosis. While its auditory benefits are well-documented, the impact on vestibular function and self-perceived dizziness remains understudied. This study utilizes the video Head Impulse Test (vHIT) and the Dizziness Handicap Inventory (DHI) to explore associated vestibular outcomes, aiming to enhance our understanding and improve clinical management of postoperative effects.
The aim of this study was to document the baseline vHIT and DHI characteristics of an otosclerosis population preceding stapes surgery, and evaluate their evolution post-operatively.
Methods: Prospective, before-and-after study. Outpatient otosclerosis patients were recruited sequentially. Vestibular evaluation consisted of a baseline vHIT and DHI, as well as two repeated evaluations at 2 weeks (2wk) and 2 months (2mo) post-operatively.
Results: The included sample consisted of 25 patients (mean age 48,2±9, 80% female). Most patients presented normal baseline vHIT (88%), and the median baseline total DHI score was 14 (IQR 25).
Mean vHIT gain on the operated ear side was 0,92±0,10 (baseline), 0,84±0,17 (2wk) and 0,90±0,08 (2mo), although difference across timepoints didn’t reach statistical significance (paired sample t-test p>0,05), as was the case with corrective saccades. Total DHI score didn’t differ significantly from baseline to any timepoint, although the score decreased significantly from 2wk to 2mo (Wilcoxon p=0,047). Only 1 patient had pos-operative acute vertigo, with subsequent self-limited resolution.
Conclusions: Although a trend was noted, these results suggest that stapes surgery per se isn’t consistently associated with vHIT variability or DHI score change, despite creating an artificial fistula between the middle and inner ear. However, they can be a reliable marker of acute post-operative vestibular events, which is in line with previously presented evidence. Limitations of this study include its low sample size, possibly yielding insufficient power to detect relevant subclinical differences.
PPIII:98 - The most reliable way of post-COVID-19 vestibular diagnostics
Sinisa Maslovara1, Tihana Mendes2, Silva Butkovic Soldo2, Ivan Kristic3, Olivera Cejic3, Tena Verlki4
1Faculty of Dental Medicine and Health, University Josip Juraj Strossmayer of Osijek, Croatia
2Faculty of Medicine, University Josip Juraj Strossmayer of Osijek, Croatia
3ENT polyclinic of the National Memorial Hospital “Dr. Juraj Njavro” Vukovar, Croatia
4Department of Social Sciences, Faculty of Educational Sciences, Josip Juraj Strossmayer University of Osijek, Croatia
Purpose: Although COVID-19 is predominantly a respiratory disease, it is often accompanied by numerous neurological symptoms. As a part of the post-COVID-19 syndrome, we note the appearance of various symptoms, among them dizziness, which should be paid special attention to in today's otoneurological diagnostics, because the post-COVID-19 dizziness accounts for a significant share of 12.66% in the total number of patients suffering from balance disorders.
Methods: Our study involved 40 patients suffering from vertigo, which has developed as a part of a chronic COVID-19 outbreak. On average, the aforementioned patients were appointed for an examination approximately two months after the end of the SARS-CoV-2 infection. We examined the impact of the disease on the results of laboratory tests of the vestibular system, including VNG (videonystagmography), video HIT (head impulse test), and VEMP (vestibular evoked myogenic potential).
Results: As expected, the largest patient group was the one comprising those with acute unilateral peripheral vestibulopathy (AUPVP). A significant number of patients are, those suffering from benign paroxysmal positional vertigo (BPPV) was detected, as were the cases of vestibular migraine and Ménière's disease. Laboratory-based diagnostics demonstrated the largest share of pathological findings in the Fitzgerald-Hallpike bithermal caloric test, performed as a part of the VNG battery of tests.
Conclusions: It has been shown that the bithermal caloric test, which corresponds to the lowest part of the frequency spectrum, correlates best with various forms of acute and chronic post-COVID-19 vestibular lesions compared to video HIT and VEMP examinations. This signifies that in the diagnosis of post-COVID-19 dizziness, we can rely on the Fitzgerald-Hallpike test as the most reliable source of data pertaining to the condition of a vestibular sense.
PPIII:99 - The Ocular Counter Roll Test and Its Crucial Role in Detecting Otolith Degeneration: A prospective study
Ireri Espinoza1, Jorge Madrigal1, Elizabeth Andalón-Dueñas1, Johanna Vanegas Munera2, Melissa Castillo-Bustamante3
1Centro de Vertigo y Mareo, Mexico
2Universidad Pontificia Bolivariana, Public Health, Colombia
3Universidad Pontificia Bolivariana, Otolaryngology Department, Colombia
Purpose: Vestibular assessments, such as the video ocular counter roll (vOCR) test, offer valuable insights into the complex interactions between age, otolith degeneration, and vestibular function.Herein, we conducted a cross-sectional study utilizing the video ocular counter roll (vOCR) test to explore the relationships between age, gender and otolith degeneration
Methods: Participants underwent vOCR testing, and otolith degeneration was comprehensively assessed. Descriptive statistics and simple linear regression analyses were employed for data analysis. The relationships were quantified using confidence intervals, R-squared values, and p-values.
Results: The general population analysis showed a statistically significant and moderately strong negative relationship between age and vOCR gains in both ears (p = 0.0032 vs p = 0.0002). Narrower confidence intervals and significant R-squared ((CI: -0.05544 to -0.01144 vs -0.06883 to -0.02269); (R2 = 0.079 vs R2 = 0.12)) highlighted the contributions of age and otolith degeneration. For females, a moderate and statistically significant negative relationship between age and vOCR gains was found in both right and left ears (p = 0.02 vs p = 0.02). The narrower confidence intervals and R-squared values ((CI: -0.06542 to -0.005400 vs -0.09666 to -0.008084); (R2 = 0.09 vs R2 = 0.14)) underscored the substantial impact of age on the variability in vOCR gains. In males, weak and non-statistically significant associations between age and vOCR gains were observed.
Conclusions: Females demonstrated a more pronounced association between age and lower vOCR gains, emphasizing potential gender-specific vestibular dynamics. These findings underscore the significance of considering gender-specific factors in interpreting vestibular test results.
PPIII:100 - THE REFIXATION SACCADES IN THE ANALYSIS OF THE VIDEO HEAD IMPULSE TEST IN INDIVIDUALS WITH VESTIBULAR SCHWANNOMA
Thiago Silva1, Kátia Alvarenga1, Fayez Junior2, Lucas Silva3, Luiza Ferreira2, Djane Santos1
1University of São Paulo, Audiology, Brazil
2University of Brasilia, Otolaryngology, Brazil
3State University of Rio de Janeiro, Otolaryngology, Brazil
Purpose: To analyze the importance of video head impulse test (vhit) refixation saccades in individuals with vestibular schwannoma (Vs).
Methods: This paper was approved by the Brazilian Ethics and Research Committee under number CAAE: 67337123.7.0000.5417. Cross-sectional study consisting of 16 individuals (9 men) with Vestibular Shwannoma who underwent vHIT. An analysis of the ocular vestibular reflex (OVR) gain and the characteristics of refixation saccades (peak velocity, latency and rate of occurrence) of the semicircular canals were performed.
Results: The Koos Granding Scale was used to separate VS according to size and location of the lesion. Of the total sample, 14 individuals (87.50%) presented changes, affecting one canal 5 (31.25%), two canals, 7 individuals (43.75%) and three canals, 2 individuals (12.50%) with a higher prevalence of changes in the side canal. Regarding VOR gain, 8 indiviaduals (50%) had low VOR gain, while 14 individuals (87.50%) of the total of the sample had refixation saccades compatible with the location of the injury. In this study, a sensitivity of vHIT in the functional diagnosis of individuals with VS of 87.50% was observed, taking into account gain and refixation saccades as analysis parameters.
Conclusions: In this study, vHIT showed high sensitivity to detect changes in the semicircular canals in individuals with VS. Regardless of the size and location of the lesion, refixation saccades are an important parameter for vhit analysis, with 87.50% of the sample presenting refixation saccades compatible with the side of the lesion, while the VOR gain was altered in 50%.
PPIII:101 - The Role of VEMPs in the Assessment of Vestibular Functions in Patients with Internal Auditory Canal Stenosis
Peng Han1, Pengyu Ren2, Qing Zhang3
1Xi'an Jiaotong University/The First Affiliated Hospital, Otorhinolaryngology, China
2Xi'an Jiaotong University/The Second Affiliated Hospital, Otorhinolaryngology, China
3Shanghai Jiaotong University/Xinhua Hospital, Otorhinolaryngology, China
Purpose: To determine the vestibular involvement in patients with internal auditory canal (IAC) stenosis using cervical and ocular vestibular-evoked myogenic potentials (cVEMPs and oVEMPs).
Methods: Twenty patients with IAC stenosis (study group) and 24 age-and-gender-matched healthy subjects (control group) were enrolled. All patients underwent air-conducted sound cVEMP and oVEMP tests. Amplitudes, thresholds, and latencies of VEMPs were evaluated.
Results: Most IAC stenosis patients showed normal VEMP response and parameters, while some patients presented abnormal VEMP (including no response and abnormal parameters). The abnormal rate of cVEMP was 40%, which indicates possible inferior vestibular nerve function damages due to the IAC stenosis. The abnormal rate of oVEMP was 30%, which indicates superior vestibular nerve function damages. The 24 controls all showed normal VEMP response and normal parameters.
Conclusions: Patients with IAC stenosis may have vestibular dysfunctions, and VEMPs could reflect the degree of damages of the vestibular nerve pathway.
PPIII:103 - Using ‘HINTS Family’ to Diagnose Acute Vestibular Syndrome: A Systematic Review and Meta-analysis
Wanxin Xu1, Xia Ling2, Hongyuan Chu1, Siru Xue1, Yuru Wang1, Zhaoxia Wang2, Xu Yang1
1Peking University Aerospace School of Clinical Medicine (Aerospace Center Hospital), Department of Neurology, China
2Peking University First Hospital, Department of Neurology, China
Purpose: Acute vestibular syndrome (AVS) often arises from benign peripheral causes, yet the critical need to distinguish dangerous causes, notably stroke, persists. The Head Impulse test, Nystagmus, Test of Skew (HINTS) examination has emerged as a bedside test to identify stroke. HINTS plus hearing loss and video-oculography-HINTS (v-HINTS) have gained traction for stroke diagnosis. We conducted a meta-analysis of these tests' diagnostic accuracy for stroke in AVS.
Methods: We searched PubMed, Embase, Web of Science, and Cochrane library for prospective studies involving AVS patients diagnosed using MRI and/or CT as the gold standard. Two authors independently screened articles, extracted data, and assessed study quality using QUADAS-2. A meta-analysis was performed using STATA (12.0) and RevMan 5.3.
Results: We included 11 studies in the analysis: 11 for HINTS (n = 1286), 2 for HINTS plus (n = 265), and 1 for v-HINTS (n = 50). Their sensitivities for stroke were 0.97 (95%CI: 0.94 - 0.99), 0.99 (0.95 - 1.00) and 1.00, with specificities of 0.81 (0.72-0.88), 0.82 (0.74 - 0.88), and 0.90, respectively. LR+ for stroke were 5.2 (95%CI: 3.3 - 8.2), 5.5 (3.8 - 8.2) and 9.75. Youden index were 0.78, 0.81 and 0.90. The AUC for HINTS and HINTS plus in diagnosing stroke were 0.98 and 0.99.
Conclusions: ‘HINTS Family’ examinations are generally effective in detecting stroke in AVS patients, especially those with stroke risk factors. HINTS plus outperforms the HINTS examination. Furthermore, v-HINTS exhibits the highest accuracy, highlighting the importance of using VOG devices for acute stroke diagnosis.
PPIII:104 - Validation of simultaneous BC ocular and cervical VEMP by unilateral BC stimulation at mastoid with transducer B250
Luca Verrecchia1, Karl-Johan Fredén Jansson2, Sabine Reinfeldt2, Bo Håkansson2
1Karolinska University Hospital, ENT Audiology and Neurotology Department, Stockholm
2Chalmers University of Technology, Biomedical signals and systems research group, Gothenburg
Purpose: The B250 is a new prototype for bone conducted (BC) stimulation. The compact design together with the strong mechanical output at low frequencies makes the B250 a valid alternative for BC stimulation in vestibular evoked myogenic potentials (VEMP). We have compared a VEMP protocol based on B250 mastoid stimulation and simultaneous recording of ipsilateral cVEMP and contralateral oVEMP (BC ocVEMP), to the laboratory BC VEMP standards in which sequential oVEMP and cVEMP are obtained with midline Minishaker B&K4810 (MS) stimulation.
Methods: 132 patients attending the balance laboratory were tested with BCocVEMP (stimulus: 250 Hz single cycle, B250 at mastoid, 135 dB FL) in comparison with BC oVEMP (125 Hz single cycle, MS at Cz, 135 dB FL) and with BC cVEMP (500 Hz single cycle, MS at Fz, 135 dB FL). Response rates, amplitudes latencies and asymmetry ratios were compared between BC ocVEMP and BC oVEMP and BC cVEMP.
Results: BC ocVEMP showed reproducible responses, with cervical amplitudes 40% larger than BC cVEMP and ocular responses 60% weaker than BC oVEMP. The response rate in BC ocVEMP was 16% higher for cervical recordings and 6% lower for ocular recordings compared to BC oVEMP and cVEMP. Latencies were comparable among the protocols. The asymmetry ratios calculated on both ocular and cervical recordings correlated well between the protocols.
Conclusions: BC ocVEMP is a valuable clinical method for the study of unilateral otolith function. Differently from MS-based BC VEMP, it is time-saving (simultaneous ocular cervical recording), not operator specific (mastoid attachment with spring steel) and easily scalable on commercial devices.
PPIII:105 - Vestibular Assessment in Children with Sensorineural Hearing Loss: diagnostic accuracy and proposed algorithm
Max Gerdsen1, Tamara Hundscheid1, An Boudewyns2, Vincent van Rompaey2, Raymond van de Berg1, Josine Widdershoven3
1Maastricht UMC, department of Otorhinolaryngology, Maastricht, the Netherlands
2University Hospital Antwerp, department of Otorhinolaryngology, Antwerp, Belgium
3Maastricht UMC, department of Otorhinolaryngology, Maastricht, the Netherlands and University Hospital Antwerp, department of Otorhinolaryngology, Antwerp, Belgium
Purpose: Vestibular assessment in children with sensorineural hearing loss (SNHL) is critical for early vestibular rehabilitation therapy to promote (motor) development or guide decision making towards cochlear implantation (timing of surgery and laterality). The aim of this study was to evaluate the diagnostic accuracy of several clinically available vestibular tests in children with SNHL to screen for vestibular hypofunction (VH).
Methods: A two-center retrospective chart review was conducted. Eighty-six patients between the age of 0 and 18 years were included in this study with SNHL. Vestibular tests included video head impulse test (VHIT), caloric test and cervical vestibular evoked myogenic potential (cVEMP). A combination of the clinical assessment and (combinations of) vestibular test outcomes determined the diagnosis. The diagnostic quality of tests and combination of tests was assessed by diagnostic accuracy.
Results: VH was diagnosed in 44% of the patients. The VHIT and caloric test showed the highest diagnostic accuracy compared to cVEMP. All combinations of VHIT, caloric test and cVEMP showed improvement of the diagnostic accuracy compared to the respective tests when performed singularly. All combinations of tests showed a relatively similar diagnostic accuracy, with the VHIT combined with the caloric test scoring the highest. Adding a third test did not substantially improve the diagnostic accuracy.
Conclusions: Vestibular testing is feasible and VH is highly prevalent in children with SNHL. A proposed diagnostic algorithm recommends starting with VHIT, followed by cVEMP for children under the age of four, and caloric testing for older children if VH is not confirmed with the first test (see Figure 1). Performing a third test is redundant as the diagnostic accuracy does not improve substantially. However, challenges remain, including the lack of a gold standard and the subjective nature of the diagnosis, highlighting the need for standardized testing and increased understanding of VH in this population.
PPIII:106 - Vestibular Dynamics During Pregnancy: A Case Series Analysis Utilizing Video Head Impulse Test
Melissa Castillo-Bustamante1, Maria Nazareth Campo-Campo2, Daniel Peña-Tobon2, Johanna Vanegas-Munera3, Jorge Madrigal4
1Clinica Universitaria Bolivariana/ Universidad Pontificia Bolivariana, Otolaryngology Department, Colombia
2Clinica Universitaria Bolivariana/ Universidad Pontificia Bolivariana. Obstetrics and Gynecology Department. Colombia
3Universidad Pontificia Bolivariana. Public Health. Colombia
4Centro de Vértigo y Mareo. Private Practice. Mexico
Purpose: This study aims to assess the impact of pregnancy on the vestibular system by evaluating semicircular canal function in thirteen participants using the Video Head Impulse Test (vHIT) from the 20th gestational week with an eight-week follow-up.
Methods: Conducted at Clínica Universitaria Bolivariana from April to June 2023, this case-series study involved weekly vHIT examinations on 13 pregnant women beyond the 20th gestational week, utilizing the EyeSeeCam device. ANOVA tests were employed to analyze semicircular canal changes over eight weeks. The study also incorporated the Dizziness Handicap Inventory (DHI) in Colombian Spanish, assessing functional, emotional, and physical scales to gauge disability related to vestibular symptoms during pregnancy.
Results: The mean age was 24.8 (SD 4.3), with gestational weeks ranging from 20.6 to 32.4 (mean gestational week 26, SD: 12.3). Primiparity was prevalent (62.5%). Noteworthy ascending trends in vestibulo-ocular reflex (VOR) gains were observed in lateral (p < 0.0001) and anterior (p = 0.0007) canals. Posterior semicircular gains displayed a significant and variable trend throughout pregnancy (p = 0.0037). No saccades were detected, and there was no significant increase in asymmetry in LARP, RALP, or lateral planes. Moderate or severe disability was reported in DHI functional (50%) and physical (55%) scales throughout pregnancy.
Conclusions: The case-series study reveals distinct trends in lateral and anterior canal gains during pregnancy, while posterior canal gains exhibit variability. These trends may be associated with volumetric and functional changes in the posterior labyrinth. Notably, moderate or severe disability persists despite these vestibular shifts throughout pregnancy.
PPIII:107 - Video-head impulse test and vestibular evoked potentials in patients with spinocerebellar ataxia
Zeljka Calic1, Alyssa Dyball2, Diego Herrero3, Nicholas Yang2, Sally Rosengren2, Andrew Bradshaw2, Kishore Kumar4, Miriam S Welgampola2
1Liverpool Hospital, Department of Neurophysiology, Liverpool, Australia
2Institute of Clinical Neurosciences, Royal Prince Alfred Hospital, Camperdown, Australia
3Faculty of Medicine of Clinica Alemana, Universidad del Desarrollo, Santiago de Chile, Chile
4Concord Repatriation General Hospital, Department of Neurology, Concord, Australia
Purpose: The spinocerebellar ataxias (SCAs) are a genetically heterogeneous group of autosomal dominantly inherited progressive disorders characterised by loss of balance and coordination. This study analyses the vestibular function as measured by the 3-dimensional video-head impulse test (v-HIT) and vestibular evoked myogenic potentials (VEMPS).
Methods: 11 patients (SCA3 n=5, SCA6 n=2, SCA7 n=3, SCA34 n=1) with mean age 54.5±12.9 years (5F/6M), were recruited from Outpatient Balance Neurology Clinic. VOR gain, catch-up saccade prevalence and first saccade amplitude, peak velocity and onset latency were examined and compared against age-matched healthy controls. Cervical and ocular-VEMPS were performed.
Results: Mean International Co-operative Ataxia Rating Scale (ICARS) was 30.9±16.5 and Scale for the assessment and rating of ataxia mean (SARA) score was 11±5.8. OVEMPS to AC and BC stimuli were absent in five (45%) patients (2 (40%) patients with SCA3 and 3 (100%) patients with SCA7). Horizontal, anterior and posterior canal (HC, AC, PC) v-HIT gains for SCAs were 0.57±0.3, 0.55±0.2, 0.56±0.3 and for controls were 0.98±0.1, 0.94±0.1, and 0.85±0.1. HC VOR-gain was reduced (<mean-2SD) in 7 (64%) patients (4 (80%) patients with SCA3, 1 (50%) patient with SCA6 and 2 (67%) patients with SCA7. Refixation saccade prevalence for HC, AC, PC were 110±76%, 29±27%, 30±24% in SCAs and 45±23%, 15±13% and 49±30% in controls. First saccade amplitude was larger, peak velocity was higher and onset latency was faster for HC and PC compared to controls (p<0.05). ICARS score was significantly higher in patient with reduced VOR gain compared to the patients with normal VOR-gain (37.7± 17 vs 19.2±3.4, p<0.05).
Conclusions: Reduction in VOR gain and absence of oVEMP responses are common in patients with SCAs. Functional impairment is higher in patients with impaired VOR response.
PPIII:108 - “Videonystagmograph to go (VNGTG)” – Smartphone Based Neurotological Tool
Georgi Kukushev
1
1VERTIGO AISMP; Military Medical Academy - Sofia
Purpose: The neurotological practice is facing the requirements of modern medical standards: objective, universal examination expertise, accepted internationally, telemedicine availability, and real control of the conduction of multicenter studies. Working on his dissertation the author of this article has created a neurotological tool based on the smartphone with custom made software and hardware. It was named “Videonystagmograph to go – VNGTG”.
Methods: After local ethic committee approval and informed consent form every patient the VNGTG was clinically tested in the everyday neurotological practice.
The VNGTG has custom made software and hardware. It could be used for video documentation with real time 3D reconstruction of head movement and position for all routine office examinations like rotatory and caloric tests, as well as bed side tests like head impulse test, position and positional vertigo, as well as routine emergency department consultations.
In addition to that some neurotological conditions could not be observed during the routine examination, because in the moment the patient has no complains.
The VNGTG could be provided to the patient in order to record the eye movements, with real time 3D reconstruction of head position and movement. The observations would be analyzed by the doctor.
VNGTG is fully capable to perform telemedicine.
Results: During the presentation all mentioned featured of the VNGTG will be visualized by videos.
Conclusions: VNGTG features all the modern tendencies for good medical practice, objective examination expertise, telemedicine, and high standards multicenter studies verification capabilities.
9. Epidemiology
PPIII:115 - Altered Body Composition in Dizziness and Vestibulopathy
Seong-Hae Jeong1, Eun Ji Kim2, Eunjin Kwon2, Sukyoung Jung3, Ji-Soo Kim4
1Chungnam National University School of Medicine/Chungnam National University Hospital, Department of Neurology, South Korea
2Chungnam National University Hospital, Department of Neurology, South Korea
3Chungnam National University Hospital, Biomedical Research Institute, South Korea
4Seoul National University College of Medicine/Dizziness Center, and Clinical Neuroscience Center, Seoul National University Bundang Hospital, Department of Neurology, South Korea
Purpose: In a novel approach, this study aims to fill a significant gap in the literature by assessing the relationship between body composition disorders and dizziness and vestibulopathy. Leveraging data from the Korea National Health and Nutrition Survey (KNHANES), we aimed to provide unique insights into potential modifiable risk factors for dizziness and improve patients’ outcomes.
Methods: This cross-sectional study drew upon a substantial dataset from the KNHANES, including 10,252 participants over 40. These participants were divided into three groups based on the outcomes of a dizziness questionnaire and a modified Romberg test: those with dizziness and vestibulopathy, those with dizziness without vestibulopathy, and a control group without these conditions. The study then used multivariate regression analysis to explore the association between body composition analysis (focusing on muscle, bone, and fat) and dizziness with vestibulopathy.
Results: Our study revealed a significantly higher prevalence of sarcopenia in participants with dizziness and vestibulopathy compared to those without vestibulopathy and the control group. The multivariate regression analysis unequivocally identified sarcopenia as an independent risk factor for dizziness with vestibulopathy, with odds ratios of 1.65 [95% confidence interval (CI): 1.09–2.49, p = 0.017], and 1.92 (OR = 1.92, 95% CI: 1.28–2.88, p = 0.002) compared to the control group. There was no difference in sarcopenia between dizziness without vestibulopathy and control groups.
Conclusions: Our findings suggest that addressing sarcopenia may play a crucial role in managing patients with vestibular dysfunction. They highlight the need for dietary and exercise interventions focused on muscle mass preservation and strengthening. This is important for preventing the array of conditions or illnesses linked to sarcopenia and helping to maintain balance.
PPIII:116 - Balance and Dizziness Problems and Related Factors: 2016 and 2019-2020 United States Health Surveys
Howard J. Hoffman1, Gregory A. Flamme2, Anne E. Hogan3, Chuan-Ming Li1, Katalin G. Losonczy2, Christa L. Themann4, Helen S. Cohen5, Bryan K. Ward6, Charles C. Della Santina6
1National Institute on Deafness and Other Communication Disorders (NIDCD), National Institutes of Health (NIH), Epidemiology, Statistics, and Population Sciences, Bethesda, Maryland, USA
2Stephenson & Stephenson Research and Consulting, Cincinnati, Ohio, USA
3Pacific University, School of Audiology, Hillsboro, Oregon, USA
4National Institute for Occupational Safety and Health (NIOSH), Centers for Disease Control and Prevention (CDC), Division of Field Studies and Engineering, Cincinnati, Ohio, USA
5Baylor College of Medicine, Department of Otolaryngology-Head and Neck Surgery, Houston, Texas. USA
6Johns Hopkins School of Medicine, Department of Otolaryngology-Head and Neck Surgery, Baltimore, Maryland, USA
Purpose: Describe the prevalence, risk factors, and outcomes of randomly-selected US adults aged 40+ years with balance and dizziness problems (BDP), i.e., vertigo, light-headedness, unsteadiness, presyncope/fainting, blurred vision with head movement, other sensations.
Methods: Data were compared from the 2016 National Health Interview Survey (NHIS) Balance and Dizziness Supplement (n=33,028) and the pre-COVID-19 pandemic National Health and Nutrition Examination Survey (NHANES), 2019-March 2020, Balance Examination and Questionnaire (n=2,551). Exams included the Standing Romberg, dynamic visual acuity (DVA), and visual contrast sensitivity (VSC). Outcome variables were falls, injuries, interrupted activities, and healthcare visits. Prevalence and risk ratios, adjusted for sociodemographic factors, were calculated using logistic regression.
Results: In NHANES, the most bothersome BDPs were unsteadiness, 8%; light-headedness, 8%; vertigo, 7%; blurred vision, 4%; other, 9%. BDP episodes lasted: less than 2 minutes (50%); 2-20 minutes (30%); 20 minutes to 8 hours (11%); longer (9%). During the past year, BDP symptoms occurred at least weekly in 29%, of which half were daily. Lifetime BDP prevalence in the NHIS was 27%; the 12-month BDP prevalence was strongly associated with age, increasing 3-fold for young versus the oldest adults. In both surveys, 45% of individuals had fallen in the past five years; half fell while experiencing BDP symptoms. Less than half with BDP had consulted a healthcare professional: 42%, NHIS; 48%, NHANES.
Conclusions: Although the NHIS sample size was 10-fold greater, NHANES included exams, which augments understanding of the most bothersome BDP symptoms and the sequelae of falling risk and healthcare burden that are similar across both surveys.
PPIII:118 - Dizziness and its associations with other symptoms in persons with post-COVID conditions – a cross sectional study
Elin Östlind1, Elisabeth Ekstrand1, Iben Axén2, Christina Brogårdh1, Agneta Malmgren Fänge1, Eva Hansson1
1Lund University, Department of Health Sciences, Lund, Sweden
2Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
Purpose: Post-COVID conditions (PCC) are a wide range of health problems experienced by some people after a COVID-19 infection. One common reported symptom is dizziness which may have a large impact on the individuals’ health-related quality of life and work ability. However, knowledge of the prevalence of dizziness and its association with other symptoms in individuals with PCC is sparse. The primary aim of this study was to explore the prevalence of symptoms of COVID-19 (acute and post) and their associations with dizziness. A secondary aim was to explore the associations of symptoms in COVID-19 (acute and post) and dizziness-related handicap.
Methods: This cross-sectional study utilized self-reported data from individuals with PCC. A questionnaire regarding symptoms of COVID-19 (acute and post), health, pre-existing dizziness, and dizziness-related handicap was administered online, and 691 persons with PCC were included in this study. Associations were analyzed using the Pearson chi-square test.
Results: Eighty-four percent reported having pre-existing dizziness and that group had a higher frequency of COVID-19 related symptoms than those without dizziness. A subsample (n= 566) responded to the Dizziness Handicap Inventory and 48.8% were categorized as having moderate or severe dizziness. That group had a significantly higher proportion of symptoms related to COVID-19 and PCC.
Conclusions: The result from this study showed a high prevalence of dizziness-related handicap and a higher proportion of symptoms in those suffering from more severe dizziness which implicates the need to identify and treat dizziness in the PCC population.
PPIII:119 - Evaluation of Disturbances in Hearing, Tinnitus, and Dizziness as Signs of COVID-19 Infection
Brian McKinnon1, Robert Africa1, Rene Zimmerer1, Zack Westenhaver1
1University of Texas Medical Branch, Otolaryngology, United States
Purpose: There have been reports and studies indicating audiovestibular disturbances in COVID-19 patients with variations in the percentage of sensorineural hearing loss (SNHL). The purpose of this study is to compare the incidence of newly diagnosed SNHL, sudden idiopathic hearing loss (SIHL), tinnitus, and vestibular disturbances between infected and uninfected patients, as well as to identify population groups at risk.
Methods: This study used TriNetX to obtain statistics on COVID-19 (+) and COVID-19 (−) patients from 61 healthcare organizations. Propensity score with 1:1 matching was used to control confounding variables. This study evaluated the relative risk of developing audiovestibular disturbances up to 1 month after a COVID-19 test and further investigated the incidence in COVID-19 (+) subset groups.
Results: Between COVID-19 (+) and COVID-19 (−) patients who had an audiogram, there was no statistically significant difference in SNHL or SIHL (SNHL: relative risk [RR] = 0.69, 95% confidence interval [CI] = 0.46–1.04; SIHL: RR = 1.00, 95% CI = 0.42–2.40). Race/ethnicity or specified comorbidity did not affect the incidence of SNHL or SIHL. There was a statistically significant difference in tinnitus and vestibular disturbances between the COVID-19 (+) and the COVID-19 (−) groups (RR = 1.29, 95% CI = 1.01–1.66; RR = 2.33, 95% CI = 2.19–2.48).
Conclusions: New onset hearing loss is not more common in patients with a positive COVID-19 test than those with a negative COVID-19 test. Audiologic evaluation is needed to verify reported hearing disturbances. Although statistically significant in specific population groups, tinnitus and vestibular disturbances may not be clinically significant due to the low incidence.
PPIII:120 - FEASIBILITY OF SEVEN VESTIBULAR TESTS AND PREVALENCE OF VESTIBULAR DYSFUNCTION IN A GERIATRIC POPULATION
Nils Guinand1, Melany Hars2, Romane Laoust3, Cecilia Ferrer Soler4, Maurizio Ranieri1, Dionisio Cueto Llerandi1, Francois Herrmann4, Aurelie Tahar Chaouche4, Christophe Graf4, Angelica Perez Fornos1, Pascal Bang1, Andrea Trombetti2
1Division of Otorhinolaryngology Head and Neck Surgery, Department of Clinical Neurosciences, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
2Division of Geriatrics and Readaptation, Department of Readaptation and Geriatrics, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland & Division of Bone Diseases, Department of Medicine, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
3Division of Bone Diseases, Department of Medicine, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
4Division of Geriatrics and Readaptation, Department of Readaptation and Geriatrics, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
Purpose: Vestibular impairments in the general population of older adults remain understudied, underdiagnosed and undertreated. Especially, there remain substantial knowledge gaps regarding the most appropriate tests to be used and the prevalence of vestibular dysfunction in this population, particularly above 75 years. We aimed to determine the feasibility of a range of vestibular tests, from bedside tests to most recent quantitative tests such as the video head impulse test (vHIT) which has gained popularity, and the prevalence of vestibular dysfunction in a geriatric population.
Methods: In this prospective observational cohort study, conducted in a geriatric hospital in Geneva (Switzerland), 106 consecutive admitted inpatients (mean age: 84.2±6.3 years; 51% female; 52% faller) were subjected to a battery of seven vestibular tests administered by a blinded specialist during their hospital stay: the head-shaking, Dix-Hallpike, supine head roll, vibration, clinical HIT and vHIT, and caloric tests. Videonystagmoscopy (SmartCam®) and vHIT (EyeSeeCam®) systems were used to record eye and head movements. We evaluated the feasibility of each vestibular test, in terms of completion rates, and the prevalence of vestibular dysfunction, according to Bárány Society's diagnostic criteria.
Results: Feasibility of vestibular tests ranged from 61.3% to 97.2%, the most feasible being the vibratory test and the least feasible being the Dix-Hallpike test. Based on Bárány Society's criteria, the prevalence of patients diagnosed with unilateral vestibulopathy, bilateral vestibulopathy presbyvestibulopathy and benign paroxysmal positional vertigo was 47.5%, 25.7%, 35.6% and 40.6%, respectively. Fallers were more likely to suffer from presbyvestibulopathy (p=0.048).
Conclusions: Our results suggest that several vestibular tests are feasible in the geriatric hospital setting and could be implemented in routine hospital clinical practice. Vestibular dysfunction was found to be highly prevalent in the population of hospitalized older adults. The clinical impact of vestibular dysfunction will be further determined. This study is supported by AURIS foundation.
PPIII:122 - Hearing loss and its association to physical functioning, dizziness and incident falls among 70-year-olds
Hugo Davidsson1, Maria Hoff2, Lina Rydén3, Therese Axelsson4, Ellen Lindell5, Ingmar Skoog3, Caterina Finizia1
1Department of Otorhinolaryngology, Head and Neck Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
2Institute of Neruoscience and Physiology, Audiology unit, University of Gothenburg, Gothenburg, Sweden
3Neuropsychiatric Epidemiology Unit, Institute of Neuroscience and Physiology, Sahlgrenska Academy, Centre for Ageing and Health (AgeCap) at the University of Gothenburg, Gothenburg, Sweden
4Department of Otorhinolaryngology, Head and Neck Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden
5Department of Otorhinolaryngology, Head and Neck Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Södra Älvsborg Hospital, Borås, Sweden
Purpose: Age-related hearing loss (ARHL) and falls are both major contributors to the health, morbidity, and even mortality among older adults. Given the aging of the population, it is important with early identification of factors associated with physical decline among older adults. We investigated self-reported health, dizziness, incident falls and objective measures of physical function and their association to hearing loss among community-dwelling 70-year-olds.
Methods: In this cross-sectional, population-based study, 1116 70-year-olds (593 women and 523 men) from the Gothenburg H70 Birth cohort study participated. Hearing was measured with pure-tone audiometry and a pure-tone average of four frequencies were used (PTA, 500, 1000, 2000 and 4000 Hz). Physical functioning was measured with 6 minutes walking test (6MWT), the 5-times Chair Stand test (CS-5) and the Sharpened Romberg (SR) test. Prevalence of dizziness, general health and incidence of falls were assessed by subject interviews.
Results: In a linear regression model, higher degree of hearing loss was associated with poorer results in tests of physical function (6MWT p=0.0001, CS-5 p= 0.0001, SR eyes open p=0.0001, SR with eyes closed p=0.02), but not with dizziness or falling. When stratified for gender, this association was still evident among men, but only seen with the 6MWT for women (95% CI -23,7 - -0,57, p=0.04). Men had higher degree of hearing loss, mainly in the high frequency range. An association between hearing loss and self-rated health was found among men, but not women (p=0.007).
Conclusions: In this population-based survey, hearing loss was associated with poorer physical functioning, and lower self-reported health among 70-year-olds. Despite this, there was no association between hearing loss and dizziness or incident falls.
PPIII:123 - Hypotonia: out of balance? The relation between hypotonia and vestibular dysfunction in children
Lena Van den Bossche1, Leen Maes2, Frederic Acke3, Marieke Fontaine1, Helene Verhelst4, Ingeborg Dhooge3
1Department of Head and Skin, Ghent University, Ghent, Belgium
2Department of Rehabilitation Sciences, Ghent University, Ghent, Belgium; Department of Otorhinolaryngology, head and neck surgery, Ghent University Hospital, Ghent, Belgium
3Department of Head and Skin, Ghent University, Ghent, Belgium; Department of Otorhinolaryngology, head and neck surgery, Ghent University Hospital, Ghent, Belgium
4Department of Internal Medicine and Pediatrics, Ghent University, Ghent, Belgium; Department of Pediatrics, Division of Pediatric Neurology, Ghent University Hospital, Ghent, Belgium
Purpose: A scoping review was performed to study the prevalence of idiopathic hypotonia in literature, and the characteristics of infantile idiopathic hypotonia. With this, we aim to look for a potential association between idiopathic hypotonia and vestibular dysfunction in young children.
Methods: The scoping review was conducted following the extended PRISMA recommendations. Eligible articles were required to report features of children with idiopathic hypotonia or a predefined synonym.
Results: After screening 4,174 articles, sixteen were eligible for inclusion. Eleven studies focused on various underlying causes of hypotonia and comprised 1150 hypotonic children of which 24% remained undiagnosed. The other articles delved into the characteristics of idiopathic hypotonic children, reporting difficulties in developmental domains such as gross and fine motor development, learning or intellectual skills, and social or behavioral skills. Clumsiness and poor coordination were commonly reported and therapy, aiming to enhance muscle strength, coordination, and balance, was often recommended. Surprisingly, none of the included articles explored a possible link to vestibular dysfunction.
Conclusions: Despite the advancements in diagnostic techniques for hypotonia, a group of children is still diagnosed with idiopathic hypotonia. Some studies highlight notable resemblances to children with vestibular impairment. Yet, none of the included studies considered any kind of vestibular testing. A vestibular dysfunction could be an underlying factor in a subgroup of idiopathic hypotonic children. A prospective study will be conducted where vestibular testing in children with idiopathic hypotonia will be performed to better elucidate the possible relationship between vestibular dysfunction and hypotonia in young children.
PPIII:124 - Medical Costs due to Dizziness/Vertigo in South Korea: Analyses Using the Public Data of HIRA
Hyo-Jung Kim1, Jae-Ryun Lee2, Hyejin Lee2, Ji-Soo Kim3
1Biomedical Research Institute, Seoul National University Bundang Hospital, Seongnam, South Korea
2Department of Family Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
3Department of Neurology, College of Medicine, Seoul National University, Seoul, Korea
Purpose: Dizziness/vertigo is one of the most common symptoms seeking medical care. Thus, analyzing the medical costs due to dizziness/vertigo is important for establishing a healthcare policy. To assess the medical costs due to the six major disorders causing dizziness/vertigo using the public data of the Health Insurance Review and Assessment Service (HIRA) in South Korea.
Methods: The medical costs were evaluated using all the claim data submitted to HIRA from January 1 to December 31, 2022. The six major vestibular disorders included for analyses were benign paroxysmal positional vertigo (BPPV), psychogenic/persistent postural perceptual dizziness (PPPD), vascular vertigo/dizziness (VVD), vestibular migraine (VM), Meniere’s disease (MD), and vestibular neuritis (VN).
Results: In 2022, 43,881,520 adults aged 20 or older in South Korea, of whom 4.11% (n=1,805,159) visited hospitals due to dizziness/vertigo. Compared to the general population, patients with dizziness/vertigo were more often elderly, female, and residents of small towns. The total healthcare cost for the six major vestibular disorders was ₩547.8 billion (approximately $406.5 million). BPPV had the highest annual medical cost (₩183.5 billion, 33.5%), followed by VVD (₩158.8 billion, 29.0%), MD (₩82.2 billion, 15.0%), Psychogenic/PPPD (₩60.3 billion, 11.0%), VN (₩32.9 billion, 6.0%), and VM (₩30.1 billion, 5.5%). The mean healthcare cost per each hospital visit due to dizziness/vertigo was ₩96,524 (95% CI = ₩96,194 - ₩96,855), 30% higher than the average (₩73,948) of overall healthcare cost due to each hospital visit over the same period.
Conclusions: Owing to higher healthcare cost for dizziness/vertigo and increased prevalence of dizziness/vertigo in aged population, the medical costs due to dizziness/vertigo would increase rapidly in South Korea. Thus, a guideline for cost-effective management of dizziness/vertigo should be established to reduce the healthcare costs due to these common symptoms.
PPIII:126 - Sick Leave Due to Ear-related Diagnoses in Mexico
Kathrine Jáuregui-Renaud1, Ismael Velázquez-Ramírez2, Jetzabel de Jetzenay Hernández-Tenorio2, María del Carmen Solis-Cruz2, Constanza Miriam Aguilar-Jiménez2, Ofelia de Jesús Morales-Sánchez2, Milliteotl Rincón-Rojas2
1Instituto Mexicano del Seguro Social, Unidad de Investigación Médica en Otoneurología, México
2Instituto Mexicano del Seguro Social, Coordinación de Salud en el Trabajo, México
Purpose: To assess the frequency of sick leave due to ear-related diagnoses in México.
Methods: Analysis on the nationally representative registry of paid sick leave certificates (not related to work injuries) that were provided in years 2018 and 2019 by the main social security institution in Mexico. The certificates were quantified according to Chapter VIII of the 10th Revision of the International Classification of Diseases (ICD-10), by sex and group of age. Comparisons by sex were perforemd using “t” test, with a significance level of 0.05.
Results: During the two years. the institution provided 22,053 sick leave certificates due to ear-related diagnoses; among them, 94.64% were those of vestibular disorders. The most frequent vestibular diagnosis was Benign Paroxysmal Positional Vertigo (75.16%), the second most frequent diagnosis was Labyrinthitis (8.5%), and the third one was Meniere’s disease (8.1%). However, the highest cumulative days of sick leave per case were related to ototoxic hearing loss, other disorders of the vestibular function, and degenerative or vascular disorders of the ear. A total of 4.63% of the diagnoses were those of external and middle ear disorders, and 0.71% were mainly related to hearing. In the fifth decade of life, compared to men, a larger proportion of women required sick leave (32.5% versus 25.6%, p=0.02).
Conclusions: In México, during years 2018 and 2019 (just prior to the SARS-CoV-2 pandemic), among 22,053 new paid sick leave certificates due to ear-related diagnoses, vestibular diagnoses were the most frequent cause of sick leave, in particular Benign Paroxysmal Positional Vertigo.
PPIII:127 - The dizzy patient’s journey: from symptom onset to specialist review
Maja Klarendic1, Lucia Joffily2, Fernando Andreiuolo3, Thomas Gomes3, Nehzat Koohi4, Jonathan Edlow5, Diego Kaski4
1Department of Neurology, University Medical Centre Ljubljana, Slovenia
2Universidade Federal do Estado do Rio de Janeiro, University College London
3Universidade Federal do Estado do Rio de Janeiro
4University College London
5Harvard Medical School, Boston, USA.
Purpose: This study aims to review clinical data regarding time to specialist diagnosis for patients with dizziness in two vestibular centres, one in Europe (UK) and one in South America (Brazil).
Methods: We retrospectively reviewed clinical registration data from patients referred to outpatient neuro-otology centres at University College London Hospitals in London, UK and Hospital Universitário Gaffree e Guinle in Rio de Janeiro, Brazil. We collected data from December 2022 to December 2023 focusing on date of symptom onset, non-specialist diagnosis, date of specialist review, and final diagnosis.
Results: 316 patients (157 from UK and 159 from Brazil) with chronic (continuous or episodic) dizziness were included: 91(28.8%) male, aged 18-96 (average age 57.8 (±16.5) years). Average time from symptom onset to final diagnosis was 54 (±64) and 43 (±64) months for UK and Brazilian centres, respectively. The most common cause of chronic dizziness in UK group was Persistent Postural-Perceptual Dizziness (35%), followed by vestibular migraine (20,4%). In the Brazilian group the most common final diagnosis was Benign Paroxysmal Positional Vertigo (35.2%) followed by vestibular migraine (20.1%). There was no correlation between age and time to diagnosis nor between the final diagnosis and correct diagnosis.
Conclusions: Our study highlights the long wait time for specialist input across health services, suggesting a common worldwide problem. It emphasises the need for establishing more efficient clinical pathways for dizziness, requiring education for primary and secondary care physicians and the need for more vestibular specialists.
PPIII:128 - Vestibular Dysfunction in Type 2 Diabetes Mellitus : prevalence and significance
Chetana Naik
1
1Ear Nose Throat & Vertigo Clinic, Consultant ENT surgeon & Neurotologist, India
Purpose: To evaluate and find the proportion of patients of Type-II Diabetes Mellitus with Sensorineural hearing loss and Vestibular dysfunction and association with glycemic control
Methods: An Observational cross-sectional study was carried out in 100 patients (Age group: 30 – 60 years) diagnosed with Type-II Diabetes Mellitus coming to the outpatient department of a Tertiary Care Hospital, fulfilling the inclusion criteria. Prior approval of Institutional Ethics Committee and written informed consent was taken. All patients were subjected to investigations to assess their Diabetes control, hearing and vestibular function. The findings were subjected to statistical analysis.
Results: Out of 100 patients ,62 were males and 38 were females between 30 to 60 years of age. The mean HbA1c level was 9.16 ± 2.4. The patients were divided into three groups depending on HbA1c level, to denote control, Good (≤7%), Moderate (>7, ≤12%) and Poor (>12%). There were total of 69 patients with Sensorineural Hearing Loss (SNHL) and 70 patients with Vestibular dysfunction. SNHL was present in 57.6% of Good control group, 66.1% of Moderate control group and 100% of Poor control group. Analysis with Chi-square test for correlation between Glycemic control and SNHL was statistically significant. Out of the 70 patients with vestibular dysfunction, 51.4% had Right Vestibulopathy, 41.4% had Left Vestibulopathy and 7.2% had a Bilateral Vestibulopathy. 22 patients had Benign paroxysmal positional vertigo. Vestibular Dysfunction was present in 42.3% of Good control group, 74.5% of Moderate control group and 100% of Poor control group. Chi square test was statistically significant
Conclusions: There is a significant association between Type II Diabetes Mellitus, and Sensorineural Hearing Loss and Vestibular Dysfunction especially with worsening of glycemic control. Screening for these debilities should be a part of the routine workup of a Diabetic patient. Vestibular dysfunction is a potential cause for imbalance and vertigo in Diabetes Mellitus.
10. Functional and Psychiatric Vestibular Disorders
PPI:02 - Abnormal neural circuits and brain network topological properties in persistent postural-perceptual dizziness patients
Kangzhi Li1, Xia Ling2, Lihong Si3, Yue Xing3, Yuru Wang3, Jianrong Wang3, Yuan Xu3, Siru Xue3, Xu Yang3
1Peking University Shougang Hospital, Department of Neurology, China
2Peking University First Hospital, Department of Neurology, China
3Peking University Aerospace School of Clinical Medicine (Aerospace Center Hospital), Department of Neurology, China
Purpose: To identify the abnormal neural circuits associated with dizziness and postural instability, and investigate the alterations in topological properties of the brain network in patients with PPPD.
Methods: Fifty subjects, including 25 patients with PPPD and 25 healthy controls (HCs), were included. Resting-state fMRI was performed on all subjects. After data preprocessing, a whole-brain functional connectivity matrix was constructed using the Bigbrain300 parcellation template as nodes. Network-Based Statistics (NBS) analysis was performed to identify abnormal neural circuits in PPPD. Graph theoretical analysis (GTA) was performed to elucidate the alterations in topological properties of the brain network in patients with PPPD.
Results: NBS analysis revealed an abnormal neural network in patients with PPPD. The occipital visual cortex, precuneus, sensorimotor cortex, multisensory vestibular cortex, cerebellum were the key nodes of the network. GTA analysis showed that the brain network of patients exhibited small-world properties, and the topological properties of their brain network were altered. Patients with PPPD showed increased characteristic path length, decreased global efficiency, local efficiency, and assortativity compared with HCs. They also showed decreased node efficiency and degree centrality in multiple nodes within the visual and sensorimotor networks compared with HCs.
Conclusions: Abnormal neural circuits existed in patients with PPPD, involving abnormal multisensory and sensorimotor integration, which may be the neural basis of dizziness and postural instability occurred in patients with PPPD. The topological properties of brain network were altered in patients with PPPD. These findings provide a new perspective to explore the pathophysiological mechanisms of PPPD.
PPI:03 - Correlating Persistent Perceptual Postural Dizziness and Sleep
Lucia Joffily1, Marco Antonio Lima2, John F Araujo3, Maira da Rocha4, Diego Kaski5
1Universidade Federal do Estado do Rio de Janeiro, University College London
2Universidade Federal do Rio de Janeiro
3Universidade Federal do Rio Grande do Norte
4Universidade Federal do Estado do Rio de Janeiro
5University College London
Purpose: This study aims to understand the correlation between sleep and PPPD.
Methods: Its an observational cross-sectional case-control study with individuals seen at the Otoneurology Outpatient Clinic from HUGG, Federal University of the State of Rio de Janeiro. 71 volunteers divided in 25 PPPD, 29 Other Dizziness (OD) (Vestibular Migraine, Meniere's Disease and Benign Paroxysmal Positional Vertigo), and 17 healthy volunteers (control group). The following wearables were used for sleep monitoring: WatchtPAT (for sleep obstructive apnea screening) for one night and Actimeter (for objective sleep quality assessment) for two consecutive weeks. They answered the Pittsburgh Sleep Quality Index (PSQI) to evaluate sleep quality. SPSS Statistics software, version 28.0 (ANOVA and post hoc), was used for data analysis.
Results: PPPD had worse sleep quality (PSQI) than both control (p<0,001) and OD (p=0,013); and also, there was statistical difference between control and OD (p=0,009), the later scored worse. Regarding the actimeter measures Sleep Efficiency was worse in the PPPD (p=0,031) and also in OD (p=0,002) compared to the control; and there was no statistical difference between PPPD and OD. Regarding sleep obstructive apnea index, we didn’t find any statistical difference between the three groups.
Conclusions: Sleep seems to be worse in those with dizziness, regardless the cause. Although objectively (actimeter) we observed no statistical difference between PPPD and OD in Sleep Efficiency, the PPPD group subjectively (PSQI) perceived poorer quality of sleep than OD. Therefore, as well as PPPD misunderstand balance, it seems that they also misunderstand sleep.
PPI:05 - Identifying fear of falling and its relationship with emotional impact of dizziness
Maria Luiza di Carlo Riato1, Vanessa Brito Campoy Rocha2, Raquel Mezzalira2, Guita Stoler2, Maria Isabel Ramos do Amaral1
1Department of Human Development and Rehabilitation, Faculty of Medical Sciences, University of Campinas, Brazil
2Ear, Nose, Throat and Head & Neck Surgery Department, Faculty of Medical Sciences, University of Campinas, Brazil
Purpose: Vestibular disorders often result in a significant impact on daily life activities, including the fear of experiencing falls. Moreover, the symptoms might lead to a higher incidence of psychological/psychiatric distresses.
Aim: To investigate the association between emotional distress and fear of falling caused by dizziness/vertigo in patients undergoing treatment at a University Hospital, using validated assessment tools - Falls Efficacy Scale-International-Brazil (FES-I-BRAZIL) and the Questionário de Impacto Emocional da Vertigem (CIEV).
Methods: Quantitative, descriptive and cross-sectional research. Subjects, aged 18+, both sexes, attending a public Otoneurology Ambulatory with dizziness/vertigo complaints and eventually, episodes of falls. Exclusion criteria involved subjects with pre-existing psychiatric disorders predating the onset of dizziness symptoms, and cognitive impairments. Vestibular diagnosis information was collected from patients’ medical records, and an anamnesis was performed. Both protocols were applied during assessments at the Ambulatory. Statistical comparisons and correlations were conducted using Pearson's correlation coefficient to analyze the collected data.
Results: 28 patients were evaluated, aged between 35 and 82 (mean 60,2+13), 19 (67,8%) females. Scores from FES-I varied from 18 to 58 points (mean 32,89 +11,8). 25(89,2%) participants were classified as high and/or moderate level of concern about falling. Scores in CIEV varied from 0 to 35 points (mean 18,6+9) and 17(60,7%) participants were classified as at-risk to develop anxiety levels from dizziness symptoms. In the group of 25(89,2%) participants classified as at-risk in FES-I, 16(64%) were also classified as at-risk in CIEV for developing pathological anxiety derived from their symptoms. FES-I and CIEV scores were positively correlated (r=0.66, p-value<0.005) suggesting a potential relationship between fear of falling and emotional distress in vestibular disorder patients.
Conclusions: Our study highlights the significant correlation between fear of falling and emotional distress in patients with vestibular disorders, emphasizing the necessity for integrated psychological support alongside medical treatment.
PPI:06 - Measure of severity of PPPD and its association with psychiatric comorbidities and perceived handicap
Christophe Lopez1, Vasiliki Meletaki1, Maélis Gobinet1, Jacques Léonard1, Maya Elzière2
1French National Center for Scientific Research (CNRS) & Aix Marseille University, Marseille, France
2Centre des Vertiges, European Hospital, Marseille, France
Purpose: Postural Perceptual Persistent Dizziness (PPPD) is a functional vestibular condition. Despite being the most common chronic neuro-otologic disorder, it remains undertreated. The Niigata PPPD Questionnaire (NPQ), developed by Yagi et al. in 2019 to assess the severity of PPPD, could be a useful tool to help in the screening and diagnosis of this condition. This study aimed to validate a French version of the NPQ and make it an available assessment tool. Moreover, we aimed to understand the characteristics of PPPD patients better.
Methods: The NPQ was translated and adapted into French. 50 PPPD patients, 50 patients with vestibular disorders without PPPD, and 50 healthy controls were included. They answered the adapted NPQ and additional questionnaires assessing trait (STAI) and state-anxiety (HADS-A), depression (HADS-D) and handicap related to dizziness (DHI).
Results: The internal consistency was high (> 0,8) for all NPQ subscales and the total score. Intergroup comparisons showed a significantly higher NPQ total score and sub-scores in the PPPD group compared to the two others. The ROC curve analysis showed a significant, but poor, discrimination of NPQ (AUC = 0.664) and its subscales. DHI scores, depressive symptoms and trait anxiety were significantly higher in PPPD patients than in vestibular patients and healthy controls. State anxiety did not differ between PPPD and vestibular patients. Finally, there was a significant correlation between the NPQ and the DHI.
Conclusions: Our study provides a better understanding of PPPD symptomatology and its assessment. It showed that the NPQ is a reliable tool that can assist in symptom assessment for a French-speaking population.
PPI:08 - Persistent Postural Perceptual Dizziness in the Paediatric Population, a Retrospective Study at a Tertiary Centre
Jawad Abdulla1, Zara Jay2, Marousa Pavlou3, Anita Wong4, Nicola Guderley4, Herra Bhutta4, Joseph Schneck4, Waheeda Pagarkar1
1Great Ormond Street Hospital, Audiovestibular Medicine, London
2Great Ormond Street Hospital, Clinical Psychology, London
3Great Ormond Street Hospital, Vestibular Physiotherapy, London
4Great Ormond Street Hospital, Audiology, London
Purpose: Persistent postural perceptual dizziness (PPPD) is a ‘chronic functional vestibular disorder’ characterised by non-vertiginous dizziness and/or unsteadiness. Little has been published on this topic in children. This study aims to describe the clinical features of PPPD in a Paediatric Vestibular clinic.
Methods: Consecutive children attending clinic in 2022/2023 who met the Barany Society consensus criteria for PPPD diagnosis were included. SPSS was used for analysis of clinical and test findings.
Results: Data from 31 children was included (age 7-17 years, mean 14 years; 22 females and 9 males). Vestibular migraine was the most common precipitating event (n=9). Others included viral illness and psychological factors. The precipitating event resolved in 13 out of the 31 patients at time of PPPD diagnosis. The mean duration between the precipitating event and PPPD onset was 1.97 (range 0-9) years and time to diagnosis was 25.66 (0-84) months. The mean number of days missed at school was 14.48 (0-30) per month and those spent indoors was 12.12 (0-30) per month. Comorbidities included migraine (n=21), Anxiety (n=14) and Autism (n=7) among others. Duration of follow up was 27.37 months on average. Management included psychological treatment (all), vestibular physiotherapy (n=12), non-customised rehabilitation (n=9) and selective serotonin reuptake inhibitors (n=4). Two children reported symptom resolution, 10 improved and 19 had persistent symptoms. Early diagnosis and initiation of treatment were associated with a better outcome.
Conclusions: PPPD in children has a significant impact on the quality of life. Further research is required in children to inform best management options.
PPI:09 - Traumatic brain injury as a trigger of persistent postural-perceptual dizziness: Prevalence and treatment outcome
Nathaniel Johnson1, Brandon Johnson1, Dmitry Esterov1, Jeffrey Staab2
1Mayo Clinic in Minnesota, Department of Physical Medicine and Rehabilitation, USA
2Mayo Clinic in Minnesota, Departments of Psychiatry and Psychology and Otorhinolaryngology - Head and Neck Surgery, USA
Purpose: To estimate the prevalence of traumatic brain injury (TBI) as a precipitant of persistent postural-perceptual dizziness (PPPD) and assess treatment outcome.
Methods: Patients with confirmed diagnoses of PPPD made at our tertiary center from January 2015 to December 2022 were identified retrospectively from electronic medical records. Two investigators independently reviewed records that documented TBI as the precipitant for PPPD to classify TBI severity, tabulate treatment modalities, and rate outcomes for patients managed at our center for at least six months using the Clinical Global Impressions – Improvement Scale (CGI-I) giving scores of 1 (very much improved – at/near remission), 2 (much improved, >50% better), 3 (minimally improved), 4 (no change), 5 (minimally worse), 6, (much worse), or 7 (very much worse). By convention, scores of 1 or 2 were considered positive outcomes. Results were compared with previous reports.
Results: 134/1503 (8.9%) confirmed cases of PPPD resulted from TBIs, which fell within the range (3.1-15.1%) of previous, smaller reports; 86% of TBIs were mild. The mean age of patients with post-TBI PPPD was 47.7±14.6 years, 7 years younger than reports of all-cause PPPD; 77 (57.4%) were female, 9 percentage points lower than all-cause PPPD. Forty-five patients were treated for at least six months; 37 (82%) received vestibular therapy, 25 (56%) psychotherapy, and 25 (56%) serotonin reuptake inhibitors. Mean CGI-I score at six months was 2.49±1.10; 24 (53.3%) patients received CGI-I scores of 1 or 2. These outcomes compared unfavorably with previous reports of treatment responses in all-cause PPPD (e.g., mean CGI-I =1.71; CGI-I =1 or 2, 67%).
Conclusions: These results indicate that approximately 9% of tertiary care patients with PPPD have TBIs as precipitants. Younger age and lower proportion of women versus all-cause PPPD likely reflected the demographics of TBI. Poorer outcomes, possibly caused by co-existing biological or psychosocial effects of TBI, merit further investigation.
PPI:10 - Utricular dysfunction has more impact on body sway than saccular dysfunction
TORU SEO
1
1St. Marianna University Yokohama Seibu Hospital, Department of Otolaryngology, JAPAN
Purpose: The establishment of vestibular evoked myogenic potentials (VEMPs) as a test for otolith function has provided insights into the pathophysiology of isolated otolith vertigo. However, their impacts on body sway are unknown. The aim of this study is to elucidate the differences in the impact on body sway between saccular and utricular dysfunctions.
Methods: We examined 32 cases diagnosed with isolated otolithic dysfunction. Saccule and utricle dysfunction were revealed by cVEMP and oVEMP results, respectively. We analyzed the results of stabilometry with eyes closed to eliminate visual influences. Results were evaluated with standardized values (Z-scores) to be independent of age and gender.
Results: Among the cases, 12 had utricular dysfunction, 13 had saccular dysfunction, and 7 had both dysfunctions. Although the results for Romberg ratio and locus length per unit showed no significant difference between the lesion sites, the utricular dysfunction resulted in a larger sway area than saccular dysfunction.
Conclusions: Utricular dysfunction had a more pronounced impact on body sway compared to saccular dysfunction. Previous animal research supports this finding. This difference in body sway can be attributed to two factors: Firstly, it is well-established that the utricle, positioned in the almost horizontal plane, is more easily stimulated when the head is upright. Secondly, neurons originating from the utricle within the lateral vestibulospinal tract are known to extend further down the pathway than those originating from the saccule within the lateral vestibulospinal tract.
PPI:11 - Vestibular evoked potentials in patients with persistent postural-perceptual dizziness - preliminary results
Rahel A. Steuri1, Rebekka Borer1, Janine Stucki2, Tatiana Brémovà-Ertl2, Fred W. Mast1, Matthias Ertl1
1University of Bern, Department of Psychology, Bern
2Universitätsspital Bern, Inselspital, Bern
Purpose: Persistent postural-perceptual dizziness (PPPD) is a chronic functional vestibular disorder. Its core symptoms include nonspinning vertigo, unsteadiness, and persistent dizziness. The symptoms are exacerbated during active or passive self-motion, or when exposed to vection stimulation. Previous research suggests modified multi-sensory processing in PPPD with inadequate top-down interactions among vestibular cortical areas. This cognitive interplay leads to visual signals being favoured over vestibular ones. To date, vestibular processing in PPPD has not been fully understood, and it remains unclear what causes the reported symptoms. To better understand sensory processing in PPPD, we investigated vestibular evoked potentials (VestEPs) during natural vestibular stimulation.
Methods: 12 PPPD patients and 12 age- and sex-matched healthy controls (HC) were sitting on a 6-degree-of-freedom motion platform which allowed for passive self-motion. Simultaneously, 64-channel EEG was recorded.
Results: The results are consistent with previous findings in healthy subjects, revealing three VestEP components (N1, P1, P2) in both groups. The amplitudes of the components did not significantly differ between groups. Visual inspection revealed similar topographies of the three VestEP components in PPPD and HC.
Conclusions: In future analyses, we will focus on late VestEP components, including P2, which are associated with more cognitive processes. This will help to better understand the causal mechanisms underlying PPPD.
PPI:12 - Vestibular perceptual thresholds in patients with persistent postural perceptual dizziness (PPPD)
Flurin Honegger1, John HJ Allum1, Kourosh Roushan2, Felix Widmer3, Christof Stieger1, Barry M Seemungal4, Heiko M Rust3
1University of Basel Hospital, Department of ORL, Switzerland
2Neuro-otologist in private practice, Switzerland
3University of Basel Hospital, Department of Neurology, Switzerland
4Imperial College London, Department of Brain Sciences, United Kingdom
Purpose: Persistent postural perceptual dizziness (PPPD) is a common functional disorder. It is characterized by a chronic sensation of dizziness which is exacerbated by upright posture. PPPD usually evolves as a consequence of a vestibular deficit or other illness. As standard clinical vestibular tests are usually normal in these patients we studied whether there are changes in vestibular perception.
Methods: 12 patients with PPPD were assessed, 10 males and 2 females (mean age 60.8 years). 5 had a history of migraine with 3 suspected to have active migraine. The diagnosis of PPPD was established according to the criteria of the Bárány Society. 24 healthy controls were assessed,11 males, 13 females (mean age 41.6 years). Vestibular perceptual thresholds were determined for yaw-plane rotations with randomly presented amplitudes of half cosine stimuli. Balance control, handedness, Dizziness Handicap Inventory (DHI), Ten-item personality inventory (TIPI) and Hospital Anxiety and Depression scale (HADS) were also assessed.
Results: Vestibular perceptual thresholds (VPT) of PPPD patients did not differ from those of normal controls. An increased number of pathologic trunk sway values during stance and gait trials were significantly positively correlated with VPT. Elevated anxiety levels were significantly negatively correlated with VPT values. There was a trend in the subgroup of patients with migraine to have lower VPT values. DHI values were not correlated with VPT.
Conclusions: Patients with PPPD did not differ from normal controls regarding VPT values for yaw-plane rotations. The correlation between increased trunk sway with higher VPT might be due to an individually increased VPT because of PPPD. Lower VPT in those subjects with higher anxiety levels might be explained by increased alertness and attention. The trend for those patients with migraine to display lower VPT might reflect altered perceptual thresholds in active migraine.
PPII:119 - A case of PPPD and bipolar affective disorders treated by Aripiprazole LAI (Long-acting Injection)
Kensuke Kiyomizu1, Takeshi Nakamura2, Kuniyuki Takahashi2, Hideki Funahashi3
1a. Department of Otorhinolaryngology and Psychiatry, Yoshida Hospital, Nobeoka, Japan. b. Department of Otorhinolaryngology, Head & Neck Surgery, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
2Department of Otorhinolaryngology, Head & Neck Surgery, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
3Department of Clinical Neuroscience, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
Purpose: Aripiprazole is the very unique antipsychotic drugs. D2 receptors are involved in hallucinations, delusions, and Parkinson's disease. LAI (Long-acting Injection) is a treatment method that is attracting attention for its ability to suppress relapse. We report this treatment because it was effective for cases of PPPD.
Methods: Out of 1518 patients with dizziness, PPPD was revealed in 259 patients (17.1%). By the way, antipsychotic drug treatment performed 110 patients with dizziness and LAI performed 5 patients.
Results: [Case presentation] She was 23-year-old woman. She had more anxiety since middle school. In X-2, she was victimized by a male stalker. She attempted suicide in X-1. In May of X, she had floating dizziness, depressed mood. She received treatment at a nearby doctor in June. In October, her brother received medical training at our hospital and thought she had PPPD, so he recommended that she see our hospital. She was referred by a nearby doctor and saw her for the first time on December 3. She shows 50 points in DHI, 8 points in THI, 24 points in PPPD Questionnaire (NPQ). Her depressive symptom scale QIDS-J was moderate 18 points. She had 2 antidepressants 20 mg of vortioxetine and 50 mg of amitriptyline. However, on April 15, the effect was limited, with 30 points in DHI and 15 points in QIDS-J, and she had hypomanic symptoms such as wasting money. Then she was diagnosed with depression due to bipolar affective disorder. Therefore, when 6 mg of oral aripiprazole (antipsychotic drugs, dopamine stabilizer) was added, the DHI became 8 points, which improved to 0 points using LAI.
Conclusions: Antipsychotic drugs are effective for intractable depression and bipolar affective disorder, and LAI are used for schizophrenia and bipolar. We thought that it might be a good treatment for chronic dizziness, in addition to antidepressants.
PPII:120 - An intractable case of MD, migraine, PPPD and schizophrenia treated by Paliperidone LAI (Long-acting Injection)
Kensuke Kiyomizu1, Takeshi Nakamura2, Kuniyuki Takahashi2, Hideki Funahashi3
1a. Department of Otorhinolaryngology and Psychiatry, Yoshida Hospital, Nobeoka, Japan. b. Department of Otorhinolaryngology, Head & Neck Surgery, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
2Department of Otorhinolaryngology, Head & Neck Surgery, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
3Department of Clinical Neuroscience, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
Purpose: MD, migraine, and PPPD are chronic dizziness diseases. We report an intractable case with schizophrenia.
Methods: Out of 1518 patients with dizziness, MD was revealed in 349 patients (23%), migraine was revealed in 66 patients (4.3%) and PPPD was revealed in 259 patients (17.1%). By the way, antipsychotic drug treatment performed 110 patients with dizziness and LAI (long-acting injection) performed 5 patients.
Results: [Case presentation] She was a 36-year-old woman. Her chief complaints were dizziness, tinnitus, hallucinations, persecutory delusions, suicidal thoughts and depressed mood. In March of X-2, she could not be contacted in Osaka and returned home. Her first visit to our hospital on November 15th. She was treated for schizophrenia. She was treated at MD in September of X. She received treatment elsewhere and visited our hospital on November 25 of X+11. She shows 96 points of DHI, 86 points of THI, 61 points of PPPD Questionnaire (NPQ). The prescription of 15 drugs from her previous doctor was sorted out. Her migraine screener scored 3/4 as migraine. She was treated with antipsychotic drugs such as paliperidone LAI 150 mg and amitriptyline 50 mg. After undergoing psychotherapy three times a week, her symptoms improved to 58 points of DHI, 42 points of THI.
Conclusions: MD, migraine and PPPD with schizophrenia is difficult to treat, but psychiatric treatment was able to reduce anxiety and alleviate dizziness and tinnitus symptoms. Continued treatment is required to stabilize mental symptoms. In recent years, polypharmacy has become a social issue, and we worked to sort out the drugs used in this case, and through drug therapy centered on LAI, use of social resources such as psychiatric day care, and frequent psychotherapy, she was cured. It seems to be a good thing that she was able to respond positively through the enthusiasm of psychiatrist and her own efforts.
11. Gait, Posture, and Locomotion
PPI:13 - A Limbic shock and postural control
Oz Zur
1
1Ben Gurion University, Israel
Purpose: The connection between dizziness and lack of balance is known; however, the speed of the effect on the physiological balance system following an acute event on the mind and emotions while creating uncertainty has not been reported or observed to date. Thus, assessing balance ability was demanded.
Methods: Two weeks after 7thOct 2024, 16 people, mean age 39 (23-65y), were assessed. Subjective questionnaires, such as ABC, SAST, and Fear of Falling, were administered, and an objective examination of the ZBS's balance ability was conducted by applying the BBalance App.
Results: ABC questionnaire was negative, SAST and FF were positive, and ZBS by BBalance App. was lower than average regarding age.
Conclusions: The physiology of balance control was affected so quickly by feelings of neglect, loss of direction, disappointment in the government leadership, and lack of trust.
PPI:14 - A Multidimensional Pseudorandom Balance Perturbation Assessment
Manami Fujii1, Sophia Chirumbole2, Andrew Wagner3, Jaclyn Cacesse4, Ajit Chaudhari5, Daniel Merfeld6
1Otolaryngology—Head & Neck Surgery, Ohio State University Wexner Medical Center, Biomedical Engineering, Ohio State University
2Mechanical and Aerospace Engineering, Ohio State University
3School of Pharmacy and Health Professions, Creighton University
4School of Health and Rehabilitation Sciences, Ohio State University
5School of Health and Rehabilitation Sciences, Ohio State University, Mechanical and Aerospace Engineering, Ohio State University, Biomedical Engineering, Ohio State University
6Otolaryngology—Head & Neck Surgery, Ohio State University Wexner Medical Center, Speech and Hearing Science, Ohio State University, School of Health and Rehabilitation Sciences, Ohio State University
Purpose: The aim of this study was to develop and validate a multidimensional balance assessment that provides pseudo-random balance perturbations in vestibular coordinates.
Methods: To measure spatially orthogonal directions of postural sway in response to stimuli delivered in the roll, pitch, RALP (Right Anterior/Left Posterior), and LARP (Left Anterior/Right Posterior) planes, we developed four different balance perturbation trajectories using sum of sinusoids (SoS) signals. The SoS trajectories were generated by summing five sinusoidal signals with the bandwidth of 0.06-1.41 Hz. The trajectories each had a peak-to-peak amplitude of approximately 1 degree. Postural sway data were collected from 24 healthy participants (4013 years of age) on a commercially available device (Virtualis Motion VR, Perault, France). The test had three conditions: (A) simultaneous roll and pitch, (B) simultaneous RALP and LARP, and (C) simultaneous roll, pitch, RALP, and LARP. CoP data were processed using a discrete Fourier transform yielding amplitude and phase as a function of frequency.
Results: Spectral data showed that sway responses were found at all perturbation frequencies and that these spectral sway responses were clearly distinguishable. When comparing the sway amplitude (normalized by the stimulus amplitude) and phase of the CoP in response to (A) roll/pitch stimuli, (B) RALP/LARP stimuli, and (C) roll/pitch/RALP/LARP stimuli, the data showed little difference between responses to roll/pitch stimuli and responses to RALP/LARP stimuli.
Conclusions: Our multidimensional perturbations yield sway that mimics the response to one-dimensional stimuli. These multidimensional perturbations provide a way to (a) perturb sway in multiple directions and (b) quantify sway in response to each perturbation. Comparing postural sway during roll/pitch conditions to RALP/LARP conditions suggests that healthy individuals show similar postural sway in response to roll/pitch stimuli that are orthogonal in both space and time and RALP/LARP stimuli that are similarly orthogonal in both space and time.
PPI:15 - A Novel Metric Characterizes Individual Differences in Sensorimotor Control of Balance
Colin Grove1, Jennifer Bartloff2, Kreg Gruben2
1Emory University, School of Medicine, Department of Rehabilitation Medicine, USA
2University of Wisconsin-Madison, School of Education, Department of Kinesiology, USA
Purpose: Comprehensive quantification of balance is paramount to understanding its underlying mechanisms. Although center-of-pressure (CP) measures are commonly used to characterize balance, our innovative approach, which combines the ground-on-feet force (F) orientation and CP, holds promise for describing whole-body control. Previously, we showed the F lines of action in the sagittal plane converge at an intersection point, and that the intersection point height (zIP) is higher in adults ≥ 60 years-old compared with adults < 60 years-old. Herein, we evaluate the effects of altering sensory conditions on zIP and contrast the influences of sensory inputs on CP displacement and zIP.
Methods: We calculated the 95% confidence interval of CP area (CPA) and zIP produced by 96 healthy adults during 60-second epochs of quiet standing in four conditions [1) eyes open, firm surface; 2) eyes closed, firm surface; 3) eyes open, foam surface; and 4) eyes closed, foam surface]. Additionally, we derived zIP- and CPA-based sensory ratios (somatosensory = condition 2/condition 1, vision = condition 3/condition 1, and vestibular = condition 4/condition 1); values > 1.0 indicate larger CPA or higher zIP in response to reduced sensory input. Spearman’s correlations were employed to interrogate associations between like sensory ratios.
Results: The somatosensory, vision, and vestibular ratios were > 1.0 for zIP and CPA in 56% and 56%, 27% and 100%, and 30% and 100%, of participants respectively. Like zIP- and CPA-based sensory ratios were not correlated.
Conclusions: Changes in zIP across sensory conditions may reflect individual differences in the control of balance that are not apparent when examining changes in CPA.
PPI:16 - Augmented reality induced balance perturbations in fallers and non-fallers, a Multisensory approach: Protocol
Eugénie Lambrecht1, Willem De Hertogh1, David Beckwée2, Luc Vereeck1, Ann Hallemans1
1Research Group MOVANT, Department of Rehabilitation Sciences and Physiotherapy (REVAKI), Antwerp University, Wilrijk, Belgium
2Rehabilitation Research Group (RERE), Vrije Universiteit Brussel, Brussels, Belgium
Purpose: This study aims: (1) to understand how head movements affect gait stability and postural balance in older adults who have a history of falls. (2) to investigate whether these responses are linked to sensory functions (specifically: vestibular, visual, and cervical sensorimotor).
This abstract outlines the study protocol.
Methods: A cross-sectional case-control study will be carried out involving community-dwelling adults aged 65 years and above. Participants will be categorized as fallers (cases) if they experienced ≥2 fall incidents in the past 12 months and with identified fall risk on the Timed Up and Go. If both conditions are negative, they will be categorized as non-fallers (controls). Recruitment will take place in community centres, service flats and through 1stline practitioners until a sample size of 100 is reached. Data collection will involve 2 main components:
1. 3D-Movement Analysis: Participants will wear an augmented-reality set of goggles that projects a hologram moving in vertical (up, down) or horizontal (left, right) directions evoking movement of the eyes and head following the hologram while standing or walking. Gait stability and postural balance reactions will be mapped based on biomechanical marker data, force plate data and electromyography.
2. Sensory function: (1) Cervical Sensorimotor Control will be measured by the Head Repositioning Accuracy test with a wireless head-mounted 3D sensor. (2) Vestibular function will be assessed through 3D-video Head Impulse Testing, examining the vestibulo-ocular reflex gain (asymmetry) and the Perez and Rey score. Static and Dynamic Visual Acuity will be measured through functional Head Impulse Testing.
Results: We expect that head movements will induce a protective gait pattern and that sensory function and balance strategies during head motions are correlated both in fallers and non-fallers. We expect a poorer sensory function and slower, less efficient balance strategies as a response to head movements in fallers compared to non-fallers.
Conclusions: NA
PPI:17 - Development and Validation of a New Two-Dimensional Pseudorandom Balance Perturbation Test
Dan Merfeld1, Andrew R Wagner2, Sophia G Chirumbole3, Jaclyn Caccese4, Ajit MW Chaudhari4
1Ohio State University, Otolaryngology, USA
2Creighton University, Physical Therapy, USA
3Ohio State University, Mechanical and Aerospace Engineering, USA
4Ohio State University, Health and Rehabilitation Sciences, USA
Purpose: We chose to develop and begin to validate a pseudo-random, multidimensional, balance perturbation test that is tailored to highlight the multidimensional contributions of vestibular function to balance.
Methods: We developed and implemented a multi-dimensional pseudorandom balance perturbation paradigm that uses two spectrally independent sum of sinusoids signals, one for each orthogonal dimension of tilt (roll and pitch) – to deliver a two-dimensional (2-DoF) balance perturbation. In a group of 10 healthy adults and 5 vestibular patients, we measured postural sway during this novel 2-DoF perturbation paradigm, as well as during each of the individual 1-DoF components.
Results: During 2-DoF perturbation conditions, we report that spectral peaks in the sway response were larger at the perturbed frequencies when compared to (1) the adjacent non-perturbed frequencies and (2) the frequencies contained within the orthogonal, spectrally independent perturbation signal. We also report that for each of the two spectra studied, the magnitude and timing of the sway response relative to the platform disturbance was similar when measured during 1-DoF (i.e., roll or pitch tilt in isolation) and 2-DoF (i.e., roll and pitch tilts delivered simultaneously) conditions. Patient data show clear deficits. For two vestibular patients, the inclusion of a roll perturbation revealed balance dysfunction that was not identified when measuring AP sway during pitch perturbations.
Conclusions: These data support that our novel perturbation paradigm was able to provoke ML and AP postural responses that were (1) specific to the roll and pitch perturbations, respectively, and (2) similar to the responses provoked by individual 1-DoF perturbations.
PPI:18 - Do Persistent Postural-Perceptual Dizziness patients really sway? An instrumental sensor-based study
Marco Tramontano1, Leonardo Manzari2, Gianluca Paolocci3, Diego Piatti3, Laura Casagrande Conti3, Giuseppe Attanasio4, Jeffrey Staab5, Iole Indovina6
1Department of Biomedical and Neuromotor Sciences (DIBINEM), Alma Mater University of Bologna, Bologna, Italy
2MSA ENT ACADEMY Center, Cassino, Italy
3Santa Lucia Foundation, Scientific Institute for Research and Health Care, Rome, Italy
4Head and Neck Department, Policlinico Umberto I, 00161 Rome, Italy
5Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA
6Brain Mapping Lab, Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy
Purpose: The aim of this cross-sectional study is to investigate the effect of Persistent Postural-Perceptual Dizziness (PPPD) on dynamic postural stability, symmetry and smoothness of gait during dynamic motor tasks.
Methods: Thirty-three participants were recruited. Eleven people suffering from PPPD (PwPPPD), 11 from vestibular hypofunction (PwVH) and 11 healthy controls (HC) were evaluated through an instrumental wearable sensor-based assessment during three different dynamic tasks: the 10-Meters Walk Test (10MWT), the Figure of 8 Walk Test (F8WT) and the Fukuda Stepping Test (FST). A set of parameters related to stability, symmetry and smoothness of gait were evaluated and then correlated with the Dizziness Handicap Inventory (DHI) scores.
Results: Lower postural stability and symmetry of gait was found in PwPPPD with respect to HC during the 10MWT, similar to PwVH. Both groups of patients also showed lower smoothness of gait with respect to HC during the eye-closed FST. However, higher symmetry was found in PwPPPD and HC with respect to PwVH during the eye-closed FST. Finally, a significant positive correlation was found between the 10MWT and DHI score in PwPPPD.
Conclusions: PwPPPD exhibit changes in dynamic postural stability when compared to HC and those with PwVH as assessed by sensor-based evaluation. When visual cues are available, stability and symmetry values are similar to PwVH’ while in absence of visual information PwPPPD demonstrate superior performance compared to PwVH. Positive correlations were also found between the self-assessed severity of dizziness symptom and instability of PwPPPD during a linear path, revealing an objective correlation of the subjective scale.
PPI:19 - Dynamic posture disturbances in patients with obstructive sleep apnea
Mario Milkov1, Miroslav Stoykov1, Silvena Baycheva2, Elena Todorova2
1University medical and dental center, Faculty of Dental medicine, Medical University - Varna
2Faculty of Dental medicine, Medical University - Varna
Purpose: The syndrome of Obstructive sleep apnea and snoring (OSAS) can be marked as the sleep disorder of the 21stcentury. With recurrent breathing cessations during sleep, sleep apnea affects most of the anatomical systems of the human body. Poor quality and quantity of sleep due to sleep apnea diminishes patients’ body balance and proper gait capabilities.
Methods: Fifty patients (30 male, 25 female), aged between 25 and 65, were examined by an otorhinolaryngologist in the period 05.2023-03.2024. A number of free prophylactic campaigns, were organized on the premises of the University medical and dental center, Medical University - Varna. All participants underwent a test with a polygraphic equipment – Home sleep apnea test (HSAT). Vestibular system and balance capabilities were tested with the following tests: VNG, vHIT, dynamic posturography. All patients filled in informed consent forms, sleep questionnaires, forms to report the intake of medications, presence of allergies and general diseases. They had their occlusion and general oral health checked by a physician in dental medicine. This study is financed by the European Union-NextGenerationEU, through the National Recovery and Resilience Plan of the Republic of Bulgaria, project № BG-RRP-2.004-0009-C02.
Results: In 75% of the patients a case of OSAS was proven, more frequent in the male participants. Moderate forms of sleep apnea were the most diagnosed. In 90% of the patients with OSAS, changes in dynamic posture were proven (longer stabilograms, with wider surfaces) speaking of higher instability. The forms of the stabilograms were pathologic (oval). Changes in Center of Gravity (CoG) were detected – shifted backwards and to the right.
Conclusions: More prophylactic campaigns aiming to diagnose sleep disturbances should be regularly organized in order to restore patient’s quality of life. Those campaigns aid specialists to cope with the negative effects of patients’ poor sleep quality and stressful daily routine.
PPI:20 - Effect of the Amplitude of Proprioceptive Perturbations on Sensory Reweighting at the Cortical Level
Esranur Yildiran Carlak1, Scott J. Mongold1, Christian Georgiev1, Antonella Iannotta1, Gilles Naeije2, Marc Vander Ghinst3, Mathieu Bourguignon4
1Laboratory of Neurophysiology and Movement Biomechanics, UNI - ULB Neuroscience Institute, Université libre de Bruxelles (ULB), Brussels, Belgium
2Laboratoire de Neuroanatomie et Neuroimagerie translationnelles, UNI – ULB Neuroscience Institute; Department of Neurology, Hopital universitaire de Bruxelles (HUB); Centre de Référence Neuromusculaire, Department of Neurology, CUB Hôpital Erasme, Université libre de Bruxelles (ULB), Brussels, Belgium
3Laboratoire de Neuroanatomie et Neuroimagerie translationnelles, UNI – ULB Neuroscience Institute, Université libre de Bruxelles (ULB), Brussels, Belgium. Service d’ORL et de chirurgie cervico-faciale, CUB Hôpital Erasme, Université libre de Bruxelles (ULB), Brussels, Belgium
4Laboratory of Neurophysiology and Movement Biomechanics, UNI - ULB Neuroscience Institute, Université libre de Bruxelles (ULB), Brussels, Belgium. Laboratoire de Neuroanatomie et Neuroimagerie translationnelles, UNI – ULB Neuroscience Institute, Université libre de Bruxelles (ULB), Brussels, Belgium.
Purpose: The relative contribution of visual, vestibular and proprioceptive sensory systems to balance maintenance changes proportionally to their reliability, which is referred to as sensory reweighting. Sensory reweighting is classically assessed with kinetic measurements of body sway in response to perturbations or deprivations of the sensory information. However, how it is encoded in the brain is less known. Therefore, the present study aims to examine sensory reweighting dynamics at the cortical level.
Methods: Twelve healthy young participants (age 24.2 ± 1.1 year; 6 females), equipped with a 64-channel EEG cap, stood on a force plate placed atop a custom-made mechanism that imposed rotation movements about the ankle joint in the sagittal plane as a continuous proprioceptive perturbation. In the baseline condition, the perturbation was a probing sinusoidal oscillation at 0.5 Hz with 0.3 degree amplitude. In the three noise conditions, the sinusoidal probe was presented amidst a random noise of amplitude 1, 2, or 4 degrees, which had no energy at 0.5 Hz. FFT analysis quantified spectral power at 0.5 Hz in the center of pressure (COP) and in EEG signals.
Results: A peak of COP power was seen at 0.5 Hz in all conditions, and it decreased as the amplitude of the noise increased, in line with a decrease in the weight assigned to the proprioceptive system. Contrastingly, in EEG signals, a peak of power at 0.5 Hz was identified in the baseline condition, but not in the noise conditions. This peak localized in the neighborhood of Cz, compatible with an origin in the sensorimotor cortex responsible for lower body control.
Conclusions: Our results highlight a differing behavior for the signature of sensory reweighing in biomechanical and cortical signals, whereby this signature is most evident in the cortical signals. Our results open avenues for the investigation of the neuronal underpinnings of balance disorders.
PPI:21 - Electrophysiological markers of impaired postural control in Parkinson’s disease
Zaeem Hadi1, Matteo Ciocca1, Solomiia Bandrivska1, Sarah Hosli1, Yen F Tai2, Barry M Seemungal1
1Centre for vestibular neurology, Department of Brain Sciences, Imperial College London, UK
2Imperial College Healthcare NHS Trust, Charing Cross Hospital, London, UK
Purpose: EEG studies focused on identifying a cortical signature for postural balance impairment as well as gait in Parkinson’s disease (PD) are sparse. Previous studies mostly focused on specific ROIs, particularly pre-frontal regions, for identifying markers of poor postural balance or gait. However, the strength of EEG is its temporal resolution and not spatial accuracy. Here we focused on identifying spectral EEG markers of poor postural balance in PD patients.
Methods: 23 PD patients and 20 age-matched healthy controls were recruited. All participants underwent a standard posturography assessment (quiet-standing) for 60s using a force platform in four conditions: hard & soft surfaces with eyes-open and closed. A 32-channel EEG was simultaneously recorded in each postural condition. All patients underwent postural assessments during the ON state of medication. Statistical analysis compared the alpha and theta band symmetry of patients and healthy and among patients with and without FOG.
Results: We predict that a disruption of alpha and theta band symmetry, due to disruption in interhemispheric communication, to be a representative marker of postural balance impairment in Parkinson’s disease and the strength of this disruption would be greater in patients with FOG. Moreover, the expected alpha-band increase with the increase in difficulty of postural condition would also be disrupted.
Conclusions: Spectral EEG markers of impaired postural control are reported in Parkinson’s disease patients.
PPI:22 - Exploring the contribution of visual motion detection acuity and proprioception to postural instability in children
Antonella Iannotta1, Scott J. Mongold1, Esranur Yildiran Carlak1, Christian Georgiev1, Pierre Cabaraux2, Gilles Naeije3, Marc Vander Ghinst4, Mathieu Bourguignon5
1Laboratory of Neurophysiology and Movement Biomechanics, UNI - ULB Neuroscience Institute, Université libre de Bruxelles (ULB), Brussels, Belgium
2Department of Neurology, Hopital universitaire de Bruxelles (HUB), Université libre de Bruxelles (ULB), Brussels, Belgium
3Department of Neurology, Hopital universitaire de Bruxelles (HUB), Laboratoire de Neuroanatomie et Neuroimagerie translationnelles, UNI - ULB Centre de Référence Neuromusculaire, Department of Neurology, CUB Hôpital Erasme, Université libre de Bruxelles (ULB), Brussels, Belgium
4Laboratoire de Neuroanatomie et Neuroimagerie translationnelles, UNI – ULB Neuroscience Institute - Service d’ORL et de chirurgie cervico-facial, Université libre de Bruxelles (ULB), Brussels, Belgium
5Laboratory of Neurophysiology and Movement Biomechanics, Laboratoire de Neuroanatomie et Neuroimagerie translationnelles, UNI - ULB Neuroscience Institute, Université libre de Bruxelles (ULB), Brussels, Belgium
Purpose: Vision and proprioception provide essential information for postural recalibration. Compared with adults, children display larger postural sways, but to which extent this relates to altered sensory processing or control strategy is unclear. Therefore, our study aims to explore the relationship between visual acuity assessed with a visual motion detection (VMD) test, proprioceptive acuity assessed with a joint position sense (JPS) test, and postural stability, and their evolution in children and young adults.
Methods: Twenty-five children (5-12 years) and 33 young adults (19-31 years) underwent a VMD test, a JPS test of the lower limb, and posturography on a hard surface or foam pads with eyes closed (EC) or open (EO). VMD acuity was the slowest detectable vertical speed of a visual gabor patch. JPS was measured as the average relative error between target and response angles. Postural instability was assessed by force plate-derived standard deviation of the center of pressure in the antero-posterior direction.
Results: Compared with adults, children displayed lower JPS (p < 0.0001), a trend towards lower VMD acuity (p = 0.059), and higher instability across conditions (p < 0.0001). Across conditions, children's instability was 3.37 - 4.04 mm higher than adults’, which ranged from 1.95 mm in EO-hard to 5.95 mm in EC-foam. Instability correlated negatively with VMD acuity in all but the EC-foam condition in adults (EO-hard, |r| = 0.36–0.44, p < 0.05), and in the EC-foam condition in children (r = -0.49, p = 0.025) but not in the others (p > 0.15). No significant correlations emerged with JPS (p > 0.2).
Conclusions: Although senses, and especially proprioception, appeared less accurate in children, our finding of limited association with postural instability suggests that they are not the primary cause of increased sways in children.
PPI:24 - Influence of verticality perception on symptoms and gait in patients with peripheral vestibular disorders
Shu-Han Wei1, Sang-I Lin2, Jiunn-Liang Wu3, Hsien-Chang Wang4, Pei-Yun Lee1
1Department of Physical Therapy, College of Medicine, National Cheng Kung University, Tainan, Taiwan
2Institute of Long Term Care, Mackay Medical College, New Taipei City, Taiwan
3Department of Otolaryngology-Head and Neck Surgery, College of Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
4Department of Digital Contents Design, Chang Jung Christian University, Tainan, Taiwan
Purpose: Vestibular system's role in accurate vertical perception is essential for orientation and balance control. To investigate the impact of misperception of verticality, this study aimed to assess how deviated subjective visual vertical (SVV) affects dizziness symptoms and gait performance in patients with peripheral vestibular disorders.
Methods: Thirty-two individuals diagnosed with peripheral vestibular disorders were recruited. All participants tested SVV by aligning a tilted rod to self-perceived vertical position against a background without visual reference. Absolute value of mean deviation in degrees relative to true vertical was used to divide the participants into two groups with a cut-off value of 3.0°. Dizziness symptoms were examined with Vertigo Symptom Scale and Dizziness Handicap Inventory. Gait performance during walking at preferred and maximum speed was assessed using a GAITRite®mat. Independent t-test was used to compare differences in questionnaires scores and gait parameters between the two groups (SVV deviation >3.0°, n=13; ≤3.0°, n=19).
Results: There was no significant difference in questionnaires scores between groups. Participants with higher SVV deviation exhibited longer double support phase in both preferred (SVV>3.0°: 34.7±7.9%, SVV≤3.0°: 29.2±6.7%, p=0.041) and maximum (SVV>3.0°: 27.2±7.0%, SVV≤3.0°: 22.6±4.3%, p=0.028) walking speed. There was no significant difference in other gait parameters between groups.
Conclusions: Although with different degrees of SVV deviation, individuals with vestibular disorders may show similar severity of subjective symptoms. However, with greater SVV deviation they might exhibit less gait stability. Self-perceived verticality should be taken into consideration when assessing gait performance in individuals with peripheral vestibular disorders for designing a more appropriate rehabilitation program.
PPI:25 - Responder analysis focusing on current intensity in postural improvement by noisy galvanic vestibular stimulation
Chisato Fujimoto1, Yayoi Kikkawa2, Makoto Kinoshita1, Teru Kamogashira1, Mineko Oka1, Kentaro Ichijo1, Kenji Kondo1, Shinichi Iwasaki3
1Department of Otolaryngology and Head and Neck Surgery, Graduate School of Medicine, The University of Tokyo
2Department of Otolaryngology, Tokyo Teishin Hospital
3Department of Otolaryngology, Head and Neck Surgery, Nagoya City University Graduate School of Medical Sciences and Medical School
Purpose: This study aimed to investigate the relationship between the effects of short-term noisy galvanic vestibular stimulation (nGVS) at different current intensities on postural control and the effects of long-term nGVS at optimal intensity performed on different days on postural control.
Methods: Subjects were 20- to 85-year-old patients with vestibulopathy refractory to vestibular rehabilitation who had the optimal intensity of nGVS. To determine the optimal intensity, the center of pressure was measured for 30 seconds in eyes-closed conditions without nGVS and with nGVS applied at 100, 200, 300, 500, 700, 1000, 1200, 1500, 1700, and 2000 μA. The optimal intensity was the current that improved velocity the most among the multiple current intensities described above. Patients who showed at least a 5% improvement in the mean percent change from pre-stimulation in velocity during the 3-hour stimulation period between the nGVS period and the placebo period were classified as the “improvement group.” The remaining patients were classified as the “no improvement group.” At each current intensity used to determine the optimal intensity, the percent change in velocity from no nGVS was compared between the improvement group and the no improvement group.
Results: The improvement group (n = 12) was significantly better than the no improvement group (n = 27) at 100 µA and 1700 µA (p < 0.05, Wilcoxon rank sum test).
Conclusions: The ameliorating effects of long-term nGVS on postural control were associated with those of short-term nGVS over a wider range of current intensities.
PPI:26 - Simple dynamic stability indicators to characterise and diagnose patients suffering from severe bilateral vestibulopathy
Gautier Grouvel1, Anissa Boutabla1, Julie Corre1, Rebecca Revol1, Samuel Cavuscens1, Maurizio Ranieri1, Jean-François Cugnot1, Raymond van de Berg2, Nils Guinand1, Stéphane Armand3, Angélica Pérez Fornos1
1Geneva University Hospitals and University of Geneva, Division of Otorhinolaryngology Head and Neck Surgery, Geneva, Switzerland
2Maastricht University Medical Center+, Division of Balance Disorders, Department of Otorhinolaryngology and Head and Neck Surgery, Maastricht, The Netherlands
3Geneva University Hospitals and University of Geneva, Kinesiology Laboratory, Geneva, Switzerland
Purpose: Although the symptoms of bilateral vestibulopathy (BV) are well known, the diagnosis of this pathology remains challenging. Recent studies have focused on understanding gait impairments mainly based on spatiotemporal parameters. However, few simple objective indicators have been proposed to help clinicians in diagnosing these disorders quickly and easily. This study aims to introduce relevant parameters for diagnosis.
Methods: Body movements of ten BV patients and ten healthy subjects (HS) during gait trials were tracked using an optoelectronic motion capture system. Spatiotemporal parameters were analysed, as well as dynamic stability parameters: extrapolated center of mass (XCoM), margin of stability, and medio-lateral distance of one foot between two successive steps (ML step distance). A non-parametric Wilcoxon test was used to assess the ability of the parameters to discriminate between the two groups. Each parameter was also classified according to the quality of the dynamic stability indicator, ease of interpretation, and feasibility of implementation in a simple clinical setting.
Results: Significant differences were found between BV and HS for the walking speed, step width, step length, maximum ML distance, XCoM movement. The classification also showed parameters easily usable by clinicians: step width, ML step distance, straight walk deviation, step crossing.
Conclusions: Identifying the parameters of dynamic instability is of great interest to better understand the pathology. Step width and ML step distance appear to be relevant for their simplicity of observation and ability to discriminate between groups. This study will provide clinicians with simple information to improve diagnosis, help identify patients at risk, and enable long-term follow-up of patients. Nevertheless, further studies are needed, including larger cohorts, to test all psychometric properties: validity, reliability, sensitivity to change. It will also be necessary to assess these parameters under more discriminating conditions (in the dark) where other sensory inputs do not compensate for the absence of vestibular function.
PPI:27 - Sound and postural control during stance tasks in compensated unilateral utricular disorder
Dietmar Basta1, Kristina Anton1, Arne Ernst1
1University of Berlin, Charité Medical School, Department of ENT at UKB
Purpose: Patients with vestibular impairment often suffer from postural instability. This could be compensated by other sensory systems such as the auditory system. The aim of this study was to investigate whether auditory input improves postural stability in patients with a compensated unilateral utricular disorder.
Methods: Young adult patients (21-36 y) with normal hearing and vision, but abnormal subjective haptic vertical participated. They showed normal results in all other vestibular testing (cVEMPs, HIT, sway measures in stance tasks) and reported no or a minor dizziness induced handicap in the Dizziness Handicap Inventory. All patients performed standing on firm ground and foam support (eyes open/closed) and Tandem Romberg test (eyes closed) in quiet (reference), noise (constant/intermitted) and with plugged ears. The tasks were conducted in a soundproofed and reverberant room. Postural stability was recorded close to the body’s center of gravity.
Results: The sway increased significantly in the two most challenging tasks (standing on foam (eyes closed) and Tandem Romberg test (eyes closed)) when noise was presented in the soundproofed room. No auditory influence on postural control was detected in all other tasks and in the reverberant room.
Conclusions: In contrast to young or elderly healthy volunteers investigated by our group earlier, no helpful effect of any auditory input was detected in patients with compensated unilateral utricular dysfunction. It seems that noise have distracted these patients from maintaining balance in challenging sensorimotor conditions where the compensatory sensory inputs are largely reduced.
PPI:29 - The impact of Bening Paroxysmal Positional Vertigo on static postural control in adults
Mari Kalland Knapstad1, Stein Helge Glad Nordahl1, Frederik Kragerud Goplen1, Jan Erik Berge1
1Norwegian National Network for Vestibular Disorders, Department of Otorhinolaryngology & Head and Neck Surgery, Haukeland University Hospital, Bergen, Norway
Purpose: In patients with BPPV, vertigo and nystagmus are triggered by head movements, and static posture with the head still should in theory not be difficult. However, we hypothesize that repeated erroneous stimuli or vestibular dysfunction impair sensory integration and postural control in this population.
Methods: We included a total of 73 participants diagnosed with BPPV from an otolaryngology clinic. All participants underwent static posturography assessing total sway area (mm2) undergoing four conditions; eyes open (EO), eyes closed (EC), eyes open on foam (EOF) and eyes closed on foam (ECF). These were compared to 47 healthy controls. Differences between groups were examined with the students t-test and linear regression were used to adjust for age and gender.
Results: Patients diagnosed with BPPV had increased sway compared to healthy controls in all conditions (p < 0.001). Adjusting for age and gender, having a diagnosis of BPPV was associated with a 69% (CI: 31 - 118%) increase in sway in the EO condition, a 66% (CI: 21-171%) increase in sway in the EC condition, a 57 % (CI: 22 - 99%) increase in the FEO condition and a 73% (CI: 37 – 118%) increase in the FEC condition.
Conclusions: These results indicate that patients diagnosed with BPPV have reduced postural control in static conditions compared to healthy controls. Thus, it is possible to speculate that having BPPV alters sensory integration due to possible continuous erroneous stimulus or static vestibular function, even without head movements.
PPI:30 - Using eye movements to assess the functional impact of bilateral vestibulopathy
Gautier GROUVEL1, Sai YADNIK1, Jean-François CUGNOT2, Anissa BOUTABLA1, Samuel CAVUSCENS1, Maurizio RANIERI1, Raymond van de BERG3, Stéphane ARMAND4, Nils GUINAND1, Angélica PEREZ-FORNOS1, Julie CORRE1
1Division of Otorhinolaryngology Head and Neck Surgery, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
2Division of Clinical Neurosciences, Geneva University Hospitals, Geneva, Switzerlan
3Division of Vestibular Disorders, Department of Otorhinolaryngology and Head and Neck Surgery, Maastricht University Medical Center, Maastricht, the Netherlands
4Kinesiology Laboratory, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
Purpose: Eye movement characteristics have been used as biomarkers of diseases like Parkinson’s and diseases or autism spectrum disorder but have not been examined as biomarkers of bilateral vestibulopathy (BV) in daily-life settings. We aimed at: 1) the characterization of eye movements patterns in BV patients in a close-to-reality laboratory setting; 2) the assessment of their validity as biomarkers, and 3) the assessment of correlations with perception of vestibular-induced handicap.
Methods: Twenty subjects with BV were compared to a group of age and gender-matched Healthy Control (HC) subjects. Participants were equipped with a wearable eye tracking device giving subjects the freedom to move naturally. Subjects had to complete 13 tasks representative of daily life normalized by difficulty in a semi-standardized environment in the hospital. Number of fixations, saccades, total gaze distance, and time to complete each task were recorded and analyzed.
Results: We observed a higher number of fixations and saccades in BV compared to HC. Total gaze distance was significantly shorter in BV compared to HC. Moreover, BV subjects took a significantly longer time than HC to complete 13 of the 15 tasks. Finally, we did not find any correlation between any of the outcome measures and the DHI scores.
Conclusions: The pattern of eye movements in BV patients is representative of their difficulty to navigate safely and efficiency in a close-to-reality environment. Eye movements appear to be good biomarkers of BV. A larger cohort would likely be necessary to observe significant correlations with self-perceived handicap.
PPI:31 - Vestibular perceptual training enhances vestibular perception, posture, and gait in older adults
Daniel C. Fitze1, Matthias Ertl1, Lorenz Radlinger2, Fred W. Mast1
1University of Bern, Department of Psychology, Bern
2University of Applied Sciences, Department of Health Professions, Bern
Purpose: Vestibular function declines with age, which is associated with the risk of falling. The highest rate of fall-related deaths or serious injuries is among people over the age of 60. We investigated the effects of vestibular perceptual training in older adults to counteract this sensory impairment, improve self-motion perception, posture, and gait.
Methods: Forty adults aged 70-88 took part in a two week motion direction discrimination training with 2800 training trials per person. Vestibular thresholds, posturography and gait parameters were measured before, during, and after training. Psychometric functions were fitted for the threshold comparison. For posture and gait the pre/post difference was predicted.
Results: Post-training, participants exhibited improved angular roll tilt and linear inter-aural translation vestibular thresholds. This indicates improved perceptual sensitivity after specific perceptual training. The perception of the untrained motion was not affected by the training. The perceptual roll-tilt training reduced body sway. Gait was mainly influenced by the inter-aural translation training, leading to an increased step size and walking speed. These training effects only manifested after the completion of the full two-week training period and were not observed after one week of training.
Conclusions: We demonstrate that vestibular perceptual training lowers perceptual thresholds and improves posture and gait parameters in older adults. These findings suggest that targeted vestibular training can provide a unique and novel intervention preventing falls, improving overall quality of life, and counteracting age-related sensory decline in aging populations. Vestibular perceptual learning can complement traditional approaches to fall prevention.
12. Genetics, Development, and Regeneration
PPI:32 - A Genome-wide Association Study in Menière’s Disease
M. Strupp1, A.M. Hartmann2, B. Konte2, I. Giegling2, A. Zwergal1, D. Rujescu2
1Department of Neurology, LMU University Hospital, LMU Munich
2Department of Psychiatry and Psychotherapy, Medical University of Vienna, Vienna, Austria
Purpose: Genetic factors seem to contribute to the development of Meniere’s disease (MD). However, a number of genetic association studies provided inconclusive results and the underlying mechanisms remain poorly understood. A genome-wide association study was conducted to identify genetic markers associated with MD.
Methods: 325 patients with definite MD (61% male) and 3403 healthy controls (46% male) of European ancestry were included and associations with approximately 7.7 million genetic variants were analyzed. Illumina and Affymetrix platforms were used for genotyping. Samples were imputed in 8 batches using IMPUTE (1000 Genomes reference panel). Markers showing deviations between batches were excluded. Population stratification was analyzed with EIGENSTRAT, standard quality control and statistical analysis with PLINK 1.9. Logistic regression corrected for age, sex and relevant principal components was applied for association analysis. Gene-based analysis was performed using MAGMA including covariates from above in an aggregated model after permutation.
Results: Top genes associated with MD (p<E-4) include 1) SMAD7 (9,00E-6), expressed in the inner ear, inhibitor of TGF-beta signaling and transcriptional repressor and 2) ANO4 (2,33E-5), expressed in the inner ear, Ca2+ activated Cl- channel with phospholipid scramblase activity. Other genes found are involved in protein transport: MAL2; tissue shape: SMAD7, MMP1, MMP10; vascular integrity: GP5, ANGPT4; cell stability: NDE, KALRN; morphogenesis: HOXC4, HOXC9.
Conclusions: These data show evidence for a set of genes which might be associated with the development of MD. Most genes show links to processes involved in structural organization of cells and tissues.
PPI:33 - A Genome-wide Association Study in Persistent Postural Perceptive Dizziness (PPPD)
Michael Strupp1, A. Hartmann2, B. Konte2, I. Giegling2, A. Zwergal1, D. Rujescu2
1Department of Neurology, LMU University Hospital, LMU Munich, Germany
2Department of Psychiatry and Psychotherapy, Medical University of Vienna, Vienna, Austria
Purpose: The pathophysiology underlying PPPD/functional dizziness is not fully understood. In order to highlight the genetic contribution to the phenotype, a genome-wide association study was conducted.
Methods: 513 patients with PPPD (47.9% male) and 3408 healthy controls (45.7% male) of European ancestry were included. Samples were genotyped on different platforms (Illumina and Affymetrix) and imputed in eight batches using the 1000 Genomes reference panel. Population stratification analysis was done with EIGENSTRAT, standard quality control and statistical analysis with PLINK 1.9. Markers showing deviations between batches in controls or cases were excluded. Association analysis was performed, applying additive logistic regression corrected for age, sex and principal components associated with the phenotype. Gene-based analysis was performed using MAGMA in an aggregated model after permutation.
Results: Top genes associated with PPPD (p<E-7) include SSTR4 (function: inhibition of release of hormones and other secretory proteins) containing the genome-wide associated variant, and genes linked to the regulation of cell proliferation (FAM83A, JADE1) and intracellular transport (WIPF1, STX11, KIF26B, SEPTINI12). CDT1 and CD83, containing GWAS top hits remain nominally significant. No gene-wide association was detected for DYRK3, SLC6A15, and SACS.
Conclusions: A genome-wide and gene-wide association study indicates genes involved in regulation of gene expression, cell growth and proliferation, and intracellular transport to be relevant for PPPD. Apart from replication studies, functional studies and pathway analyses remain to be conducted in order to evaluate whether combinatory effects of indicated genes are possible.
PPI:34 - Comparison of vestibular function in hereditary hearing loss patients with GJB2, CDH23, and SLC26A4 variants
Keita Tsukada1, Shin-ya Nishio2, Yutaka Takumi1, Shin-ichi Usami2
1Shinshu University School of Medicine, Department of Otorhinolaryngology Head and Neck Surgery, Japan
2Shinshu University School of Medicine, Department of Hearing Implant Sciences, Japan
Purpose: The cochlea and vestibule are histologically adjacent and evolutionarily and embryologically similar. Our previous review showed that numerous genes expressed in the cochlea were also expressed in the peripheral vestibular organs. Therefore, a phenotype of vestibular dysfunction may appear in addition to the phenotype of hearing loss in patients with variants in the causative genes of hearing loss. However, few studies have focused on vestibular function in patients with hereditary hearing loss. To the best of our knowledge, this is the first study to compare vestibular function in patients with the major causative genes of hearing loss.
Methods: To investigate the association between hereditary hearing loss and vestibular function, we compared vestibular function and symptoms among patients with GJB2, SLC26A4, and CDH23 variants. Thirty-nine patients with sensory neural hearing loss (11 males and 28 females) with biallelic variantss in either GJB2, SLC26A4, or CDH23 were included in this study (13 GJB2, 15 SLC26A4, and 11 CDH23). The patients were examined using caloric testing and cervical and ocular vestibular-evoked myogenic potentials (cVEMP and oVEMP). We also compared vestibular function and symptoms between patients with these mutations and 78 normal-hearing ears without vestibular symptoms as controls.
Results: The frequency of semicircular canal hypofunction in caloric testing was higher in patients with SLC26A4 variants (47%) than in those with GJB2 (0%) and CDH23 variants (27%). According to the cVEMP results, 69% of patients with GJB2 variants had saccular hypofunction, significantly higher than in those with other variants (SLC26A4, 20%; CDH23, 18%). In oVEMP, which reflects utricular function, there was no difference in the frequency of hypofunction among the three genes (GJB2, 15%; SLC26A4, 40%; and CDH23, 36%).
Conclusions: It can be considered that there are tendencies for vestibular dysfunction in each gene. These results will also facilitate the clinical application of genetic counseling.
PPI:35 - Developmental profiling of non-sensory vestibular epithelium reveals ionic contribution to endolymph formation
Sang Hyun Kwak1, Seong Hoon Bae2, Jinwoong Bok3, Sung Huhn Kim2
1St. Vincent’s Hospital, The Catholic University of Korea, College of Medicine, Department of Otorhinolaryngology, South Korea
2Yonsei University, College of Medicine, Department of Otorhinolaryngology, South Korea
3Yonsei University, College of Medicine, Department of Anatomy, South Korea
Purpose: In the inner ear, various ion channels play a pivotal role in signal transduction, and any dysfunction in these channels can result in hearing and vestibular disorders. Endolymph, crucial for inner ear function, starts forming during embryonic development. We understand potassium ion is necessary for endolymph formation at postnatal. However, we still don’t know which ion is responsible for endolymph formation at developmental stage
Methods: We collected non-sensory epithelium specimens from the vestibule at different developmental stages: E16.5, E18.5, and P5. These specimens were categorized based on the presence of dark cells. We conducted RNA sequencing to analyze changes in ion channel expression during development. Candidate genes were selected for further functional studies. 3D live imaging and ion channel inhibitors were utilized to measure endolymphatic volume changes. Immunohistochemistry was employed to examine the localization of candidate ion channels. Finally, we measured ionic current from dark cell on non-sensory epithelium of utricle by vibrating probe.
Results: We identified 1613 differentially expressed genes (DEGs), primarily associated with ion transport. Clustering analysis revealed distinct gene expression patterns corresponding to different cell types and developmental stages. Our study highlighted sodium, chloride, calcium, and potassium ions as major players in endolymph formation. Functional studies demonstrated the effectiveness of chloride-free solution and amiloride in blocking endolymphatic fluid secretion at E16.5Interestingly, calcium-free solution did not affect secretion rate, while potassium ions influenced secretion only at P5, as confirmed by XE991 treatment. We found out that benzamil(ENaC blocker) act as lowering ionic current from dark cell at E16.5.
Conclusions: During inner ear development, sodium and chloride ion is strongly likely to be associated with endolymphatic fluid secretion. This finding may contribute to elucidating the mechanism of inner ear formation and possible mechanism for congenital hearing loss and vestibular disorders.
PPI:36 - Downbeat nystagmus and BVP: Frequent monogenetic causes are changing the landscape – results of 4 large studies
M. Strupp1, F. Heindl1, D. Pellerin2, A. Traschütz3, A. Hartmann4, D. Rujescu4, C. Dufke3, T. Haak3, M. Synofzik3
1Department of Neurology, LMU University Hospital, LMU Munich
2Department of Neurology and Neurosurgery, Montreal Neurological Hospital and Institute, McGill University, Montreal, QC, Canada
3Division Translational Genomics of Neurodegenerative Diseases, Hertie-Institute for Clinical Brain Research and Center of Neurology, University of Tübingen, Tübingen, Germany
4Department of Psychiatry and Psychotherapy, Medical University of Vienna, Vienna, Austria
Purpose: The cause of seemingly “idiopathic” downbeat nystagmus (DBN) syndrome and bilateral vestibulopathy (BVP) remains unknown in a substantial number of patients. We hypothesized that monogenetic causes - specifically GAA-FGIF14 and RFC1 repeat expansions - may present a common cause of DBN and BVP.
Methods: We systematically screened large patient cohorts with DBN and BVP (with or without additional polyneuropathy (PNP) and/or cerebellar ataxia (CA)) for GAA-FGF14 and RFC1 repeat expansions.
Results: DBN: The frequency of FGF14 expansions was 48% (82/170) in patients with DBN (who did not have RFC1 expansions). Patients carrying (GAA)≥200 repeats had a significantly greater (80%) response to 4-aminopyridine compared to patients carrying a (GAA)<200 allele (31%). Biallelic RFC1 expansions were identified in 15/65 patients with DBN (23%) (who did not have FGF14 expansions).
BVP: Biallelic RFC1 expansions were identified in 10/127 patients (8%) with BVP and 1/41.
The FGF14 repeat locus was genotyped in 45 patients with a combination of CA+PNP+/-BVP who were negative for biallelic RFC1 expansions. The frequency of FGF14 expansions was 38% (17/45) in the entire cohort, 38% (5/13) in the subgroup with CA+PNP, 43% (9/21) in the subgroup with CA+BVP and 27% (3/11) in patients with all 3 features. BVP was observed in 75% (12/16) of GAA-FGF14-positive patients.
Conclusions: Both FGF14 GAA and RFC1 repeat expansions are a common monogenic cause of DBN as well as BVP. Patients with DBN due to FGF14 expansions had a high response rate to a treatment with 4-aminopyridine. FGF14 expansions is a frequent genotype of the CA+/-PNP+/-BVP phenotype.
PPI:37 - Estimating the causal effect of depression on vestibular disorders: A Mendelian randomization study
Junyu Wu1, Gengxin Lu1, Haiwei Huang1
1The First Affiliated Hospital of Sun Yat-sen University, Department of Neurology, China
Purpose: Observational studies have documented an association between depression and vestibular disorder (VD), but the causal effect of depression on VD remains unexplained. Using the Mendelian randomization (MR) method, we intended to evaluate the causal relationship between depression and VD.
Methods: The analysis employed two sets of genetics instruments derived from publicly available genetic summary data. One consisted of 38 SNPs strongly associated with major depressed disorder (MDD) and the other consisted of 63 SNPs associated with depressed affect. MR analyses employed Inverse variance weighted (IVW) method, weighted median method and MR-Egger regression. The MR-PRESSO analysis, the MR-Egger intercept analysis, and Cochran's Q statistical analysis were also utilized to detect the potential heterogeneity and directional pleiotropy.
Results: IVW analysis revealed evidence of an association between MDD and VD risk (OR = 1.25, 95% CI = 1.06-1.48, p<0.01). Using the IVW method (OR = 1.83, 95%CI = 1.33-2.52, p<0.001), MR-Egger regression (OR = 6.29, 95%CI = 1.42-27.93, p = 0.019), and weighted median approaches (OR = 1.74, 95%CI = 1.11-2.75, p = 0.017), substantial evidence for an effect of depressed affect on the incidence of VD was additionally identified. The “leave-one-out” analysis demonstrated that our results were robust even in the absence of a solitary SNP. According to the MR-Egger intercept test and MR-PRESSO analysis, genetic pleiotropy did not affect the results. In addition, Cochran's Q test did not identify any heterogeneity.
Conclusions: The large MR analysis indicated that depression may be causally associated with a risk of VD.
PPI:38 - Hearing and vestibular assessment in Usher Syndrome
Ana Margarida Amorim1, Ana Beatriz Ramada2, Ana Cristina Lopes2, João Lemos3, João Carlos Ribeiro1
1Department of Otorhinolaryngology, Local Health Unit of Coimbra, Faculty of Medicine, University of Coimbra, Portugal
2Department of Otorhinolaryngology, Local Health Unit of Coimbra
3Department of Neurology, Local Health Unit of Coimbra, Faculty of Medicine, University of Coimbra, Portugal
Purpose: To investigate genotype-phenotype correlations in Usher syndrome (USH).
Methods: Thirty-five USH patients were included, categorized into three genetic-based groups 1 (USH1, n=11), 2 (USH2, n=21), and 4 (USH4, n=2). The functional impact of dizziness was assessed using Dizziness Handicap Inventory (DHI). Participants underwent pure tone threshold testing, bithermal caloric testing, video Head Impulse test (vHIT), ocular (oVemp) and cervical (cVemp) vestibular myogenic potentials, and posturography. Genotype-phenotype associations were analysed.
Results: Total DHI could only distinguish USH1 (25.71±21.04) from USH2 (50.13±22.54) (p=0.024) but not between the three groups. Hearing loss in USH1 was significantly greater than in USH2 and USH4 (p<0.001). USH1 showed greater caloric weakness than USH2 and USH4 (p<0.004). vHIT in USH1 demonstrated lower overall gain than in USH2 and USH4 (p<0.001). USH1 showed higher number of absent cVemp responses in the right and/or left ear when compared to USH2 and USH4 (p<0.001). USH1 showed higher number of absent oVemp responses in the right and/or left ear when compared to USH2 and USH4 (right ear p<0.007; left ear p<0.023). In posturography, the vestibular compound of the sensorial organization test could not distinguish between USH groups.
Conclusions: Contemporary hearing and vestibular assessment was able to differentiate between USH groups, even though we could find vestibular disease in all groups.
PPI:39 - Redistribution of the neuroglia phenotypes in the medial vestibular nuclei after unilateral labyrinthectomy
Jie Li1, Yini Li1, Pengjun Wang1, Haibo Shi1, Shankai Yin1
1Shanghai Sixth People's Hospital, Department of Otolaryngology-Head and Neck Surgery, China
Purpose: Glial cells are highly heterogeneous and commonly involved in the regulation of neural circuit function. However, how the neuroglia in the deafferented vestibular nuclei reacts to the acute unilateral vestibular dysfunction remains unclear. Our study aims to investigate the response status of neuroglia in the medial vestibular nucleus (MVN) after unilateral vestibular loss.
Methods: The medial vestibular nucleus was harvested from C57BL/6J mice that were sacrificed 1 day after unilateral labyrinthectomy and dissociated into single-cell suspension. The cDNA library was constructed and sequenced on Illumina HiSeqX10. Downstream analysis was performed using the R packages.
Results: We discovered four subtypes of astrocytes in the MVN with each displaying unique gene expression profiles. After unilateral labyrinthectomy, we observed an elevated proportion of the astrocytic subtype associated with synaptogenesis in the ipsilateral MVN compared with the control group. The distribution of oligodendrocyte lineage cells differed as well. Oligodendrocyte precursor cells increased after vestibular loss. A cluster of highly expressed Tcf7l2 and Enpp6 was defined as premyelinating oligodendrocytes, which is one of the dominant oligodendrocyte subtypes in the deafferented MVN but rarely seen in the control group. These changes indicate a progression of oligodendrocyte differentiation.
Conclusions: Our findings reveal the adaptive changes of glial cells in the early vestibular compensation following peripheral vestibular damage, implicating the potential roles of neuroglia in remodeling neural circuits to reverse behavioral deficits.
PPI:40 - Regional division of labor in sensory processing within vestibular sensory organs of the inner ear
Youngrae Ji1, Kazuya Ono2, Tracy Fitzgerald3, Kathleen Cullen4, Doris Wu5
1Brain Institute, Daegu, South Korea
2Department of Pharmacology, Osaka University, Osaka, Japan
3National Institute on Deafness and Other Communication Disorders, National Institutes of Health
4Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, MD 21205
5National Institute on Deafness and Other Communication Disorders, National Institutes of Health, MD 20892
Purpose: The vestibular sensory organs of the inner ear are regionally specialized. Each of the five vestibular sensory organs - two maculae and three cristae - contains a specialized region known as the striola and central zone, respectively. In addition, the two maculae exhibit a line of polarity reversal (LPR), which divides each macula into two regions of sensory hair cells with opposite hair bundle orientation. To address the function of these specializations, we generated a conditional knockout mouse mutant in which the striolar and central zones are replaced with extrastriolar and peripheral zone identity, thus named as the striolarless mutant. We also generated a LPR mutant which lacks the LPR, and all the hair bundles in the maculae are unidirectional. Both types of mutants are viable which allow functional assessment of these specializations in vivo.
Methods: We conducted several vestibular tests on the two types of mutants such as vestibular evoked potential (VsEP), vestibular ocular reflex (angular VOR), off-vertical axis rotational response (OVAR), swimming, rotarod, and balance beam.
Results: Our results showed that the striolarless mutants exhibit head tremor and only remnants of VsEP. However, these mutants have no difficulty in swimming and both the aVOR and OVAR are similar to controls. In contrast, the LPR mutants exhibit panic swimming behavior in water and only mild directional deficits in VsEP.
Conclusions: Based on the differential functional deficits observed in the striolarless and the LPR mutants, we propose that the vestibular sensory organs are regionally divided to encode specific sensory inputs.
14. Meniere’s Disease and Related Disorders
PPI:51 - A case of delayed endolymphatic hydrops in which secondary endolymphatic hydrops could be confirmed by enhanced 3T MRI
Kota Hirose1, Keita Tsukada1, Kentaro Mori1, Yutaka Takumi1
1Department of Otorhinolaryngology Head and Neck Surgery, Shinshu University School of Medicine
Purpose: Delayed endolymphatic hydrops (DEH) causes recurrent vertigo or hearing fluctuations in the better hearing ear after the onset of unknown or known unilateral severe sensory neural hearing loss (SNHL). It is presumed that the lesion of preceding severe sensorineural hearing loss causes secondary endolymphatic hydrops (ELH) in the inner ear over several years. However, it is unknown whether ELH is occurring at the same time as acute deafness, or whether the ELH occurs several times after the onset of the preceding hearing loss. This case is the first to successfully demonstrate the ability to follow changes of ELH in DEH patients over time, by using Gd-enhanced 3T MRI.
Methods: A case is a 55-year-old woman. At the age of 52, acute hearing deterioration that resulted in profound deafness at her right ear occurred. After that, from the age of 54, vertigo attacks of about 30 minutes to half a day, about once or twice a month, began to be observed. In this case, the Gd-enhanced 3T MRI was performed at two occasions.
Results: No obvious ELH was observed at the very early stage of the onset of acute deafness. On the other hand, we were able to identify significant cochlear and vestibular ELH on the side of the severe SNHL when the clinical symptoms of DEH began to appear after several years.
Conclusions: We have demonstrated that ELH occurs over time after severe SNHL even in living DEH subjects.
PPI:53 - Asymptomatic endolymphatic hydrops on hydrops MR imaging
Kao-Tsung Lin1, Yi-Ho Young2
1Department of Otolaryngology, National Taiwan University Hospital, Taipei, Taiwan
2Department of Otolaryngology, Far Eastern Memorial Hospital, New Taipei, Taiwan
Purpose: This study utilized hydrops MRI in unilateral Meniere’s disease (MD) patients to clarify clinical significance of asymptomatic endolymphatic hydrops (EH).
Methods: Fifty-seven patients with unilateral definite MD were enrolled. The ears of 9 patients with positive EH on both ears were subsequently divided into two subgroups, i.e., “symptomatic EH on the affected ear” (Group A1) and “asymptomatic EH on the unaffected ear” (Group A2). The remaining 48 patients with positive EH on only one ear were assigned to Group B.
Results: The abnormality rates of the inner ear test battery in Groups A1 and B, but not in Group A2, revealed a significantly decreasing trend from the audiometry, cervical and ocular vestibular–evoked myogenic potential tests, to the caloric test. Comparing the abnormality rates, significant difference was only identified in the audiometry among the three groups, but not in the vestibular test battery.
Conclusions: If the unaffected ear exhibits fluctuating or progressive sensorineural hearing loss in a unilateral MD patient, it may suggest a transitional phase from unilateral MD towards bilateral MD. Conversely, if repeated audiometry remains normal hearing on the unaffected ear, asymptomatic EH rather than MD in that ear is indicated.
PPI:54 - Caloric test and video head impulse test discrepancy in endolymphatic hydrops-related disease
Makoto Kinoshita1, Chisato Fujimoto1, Kento Koda1, Kentaro Ichijo1, Mineko Oka1, Teru Kamogashira1, Kenji Kondo1
1University of Tokyo, Department of Otolaryngology and Head and Neck Surgery, Japan
Purpose: Some patients present with canal paresis (CP) in the caloric test (c-test) and normal vestibulo-ocular reflex (VOR) gain in the video head impulse test (vHIT). It has been previously reported that this discrepancy between these two tests indicates endolymphatic hydrops (EHs). This study aims to elucidate the relationship between the c-test/vHIT discrepancy and the EHs in inner ear gadolinium-enhanced MRI (ieMRI).
Methods: We retrospectively reviewed the medical records of 72 patients with unilateral Meniere’s disease (MD) and 19 patients with delayed endolymphatic hydrops (DEH). Results of vHIT were expressed as vHIT(+) for abnormal and vHIT(-) for normal, with a VOR gain of less than 0.8 in the lateral semicircular canal (LSCC) on the affected side being considered abnormal. Results of the c-test were expressed as CP(+) for abnormal and CP(-) for normal, with a CP percentage of 20 or greater on the affected side being considered abnormal. In MD and DEH, we statistically examined the relationship between the c-test/vHIT discrepant finding, i.e. CP(+)/vHIT(-), and the findings of vestibular-EHs and herniation to the LSCC on ieMRI.
Results: CP(+)/vHIT(-) in MD accounted for 41.2%. The correlation coefficients between this discrepant finding and vestibular-EHs and herniation showed significant correlations of 0.60 and 0.82, respectively. On the other hand, CP(+)/vHIT(-) was observed in 84.2% of DEH cases, but no significant association was observed between this discrepant finding and vestibular-EHs or herniation.
Conclusions: The CP(+)/vHIT(-) finding in MD was associated with vestibular-EHs and herniation to the LSCC in the affected ear.
PPI:57 - Diagnostic Test Accuracy of a Glycerol Test Relying on Intravenous Infusion for Meniere's Disease
Zhanguo Jin1, Yiling Li1
1Air Force Medical Center of Chinese PLA, Balance Disorders medical Center, China
Purpose: We changed the method of glycerol intake from oral administration(1.2ml/kg glycerol) to intravenous infusion (250ml Glycerol Fructose and Sodium Chloride Injection) in the glycerol test and tried to compare their diagnostic accuracy.
Methods: We randomly divided 42 MD patients into two groups: the oral group and the intravenous group. Hearing tests such as pure tone audiometry(PTA), distortion product otoacoustic emission, auditory brainstem response, speech recognition rate, and vestibular evoked myogenic potential were conducted before and after the intake of glycerol. The blood concentration of glycerol was detected in 5 patients of the oral group and 6 patients of the intravenous group.
Results: The positive test results(at least one positive hearing test) after oral compared to i.v. administration occurred in 16(76.19%) and 14(66.67%) cases, showing no statistical difference(χ
2
=0.467, P=0.495). The incidence of headache, bellyache, or nausea in the intravenous group(7.69%) was significantly lower than that in the oral group(82.35%)(P˂0.01). There was a significant difference in the blood concentrations of glycerol between the oral group(1854.22±700.83) and the intravenous group(312.78±219.91) (t=5.095, P=0.002). However, there was no significant correlation between glycerol blood concentration and positive test results (t=-1.825, P=0.111).
Conclusions: The glycerol test relying on intravenous infusion showed great diagnostic test accuracy and a low adverse reaction rate. It can be applied to the clinical diagnosis and classification of MD.
PPI:58 - Diagnostic Value of the Vestibular Autorotation Test in Menière's Disease and Vestibular Migraine
Sulin Zhang1, Jun Wang1, Dan Liu1, E Tian1
1Department of Otorhinolaryngology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan City, Hubei Province, P. R. China
Purpose: Vestibular migraine (VM) and Menière's disease (MD) share multiple features in terms of clinical presentations and auditory-vestibular functions, and, therefore, more accurate diagnostic tools to distinguish between the two disorders are needed.
Methods: The study was of retrospective design and examined the data of 69 MD patients, 79 VM patients and 72 MD with migraine patients. Five vestibular autorotation test (VAT) parameters, i.e., horizontal gain/phase, vertical gain/phase and asymmetry were subjected to logistic regression. The receiver operating characteristic (ROC) curves were generated to determine the accuracy of the different parameters in the differential diagnosis of MD and VM.
Results: Our results showed that the horizontal gain of VAT significantly outperformed other parameters in distinguishing MD and VM. In addition, the sensitivity, specificity and accuracy of the horizontal gain were 95.7%, 50.6% and 71.6%, respectively, for the differentiation between VM and MD. In most MD patients, the horizontal gain decreased in the range of 3-4 Hz, while in most VM patients, horizontal gain increased in the range between 2-3 Hz. More MD with migraine patients had an increased horizontal gain when the frequency was less than 5.0 Hz and had a decreased horizontal gain when the frequency was greater than 5.0 Hz.
Conclusions: Our study suggested the VAT, especially the horizontal gain, as an indicator, may serve as a sensitive and objective indicator that helps distinguish between MD and VM. Moreover, VAT, due to its non-invasive and all-frequency nature, might be an important part of a test battery.
PPI:59 - Dizziness is an indicator of poor hearing prognosis in the patients with otitis media-induced inner ear disorders
KAZUHIKO KUBO1, SOHICHIROH MORIYA2, TAISHI KII3
1Chidoribashi General Hospital, Department of Otorhinolaryngology & Head and Neck Surgery, JAPAN
2Kyushu Central Hospital, Department of Otorhinolaryngology, JAPAN
3National Hospital Organization Kyushu Medical Center, Department of Otorhinolaryngology & Head and Neck Surgery, JAPAN
Purpose: Otitis media occurs sometimes with inner ear disorders. This inner ear trouble is thought to be induced by increased permeability of round window, interaction with endotoxin, reduced blood flow, etc. The incidence of otitis media-induced inner ear disorders (OM-IED) such as hearing loss and dizziness are reported approximately 8-16%. In general, dizziness is more curable than hearing loss in the patients with OM-IED. Therefore, the aim of this study is to determine risk factors about the poor prognosis of hearing loss.
Methods: Twenty-four patients with hearing loss as OM-IED were recruited at Chidoribashi General Hospital. The various parameters such as age, sex, hearing level, dizziness and treatment were collected from electric medical records retrospectively. The association with hearing loss was statistically evaluated using JMP Pro 17. The current study was approved by our ethical committee.
Results: Twelve patients had full recovery while seven patients did not improve fully. The patients with dizziness had significantly worse recovery of hearing than the patients without dizziness.
Conclusions: This study indicates that the patients with both hearing loss and dizziness as OM-IED may need to be treated vigorously.
PPI:61 - Effect of Zexie Decoction on the activation of ENaC and Na+ K+-ATPase in the cochlear epithelium of rat Meniere’s model
Liqun Zhong1, Xin Wang1, Jian Li1, Zhanfeng Yan1
1Beijng University of Traditional Chinese Medicine/ Dongzhimen Hospital/Neurology Department, China
Purpose: To explore the potential mechanisms of Zexie Decoction in reducing endolymphatic hydrops through activating epithelial sodium channels and Na+-K+-ATPase during the onset of rat manière’s model.
Methods: 4 weeks aged rats were procedure for preparing manière’s model by i.p. injecting DDAVP (6 μg/kg/day) for 10 consecutive days. And then rats were divided into model group, dexamethasone sodium phosphate treatment group, and Zexie Decoction treatment group (8 rats in each group). The medication was administered once daily for 14 consecutive days. Furthermore, H&E and IF staining, ELISA, and biochemical analysis was adopted for all kinds of measurements.
Results: Zexie decoction regulates the expression of ENac/Na+-K+-ATPase to interfere with EH. Animal experiments have indicated that activation of AVP-V2R pathway upregulates ENac activity along with Na+-K+-ATPase activity, and α-ENac and β-ENac may play pivotal roles in EH development.
Conclusions: Zexie Decoction regulates ENac activity to promote Na+absorption for inner ear Na+ transport processes, reducing volume of endolymph without renal toxicity when used short-term, and having no significant effects on renal ENac,GR,MR activities.
PPI:63 - Frequency Characteristics of Vestibular Function Damage in Meniere's Disease
Wei Wang1, Shanshan Li1, Taisheng Chen1, Xueqing Zhang1, Kaixu Xu1
1Tianjin First Central Hospital
Purpose: To analyze the frequency characteristics of vestibular function damage in Meniere's disease patients.
Methods: Meniere's disease patients, 37 people, 15 men, 22 women, age 46-69 years old.All ther paitients accept the video-head impulse test, the head shaking test, the caloric test, and the sinusoidal harmonic acceleration test. The gain of vHIT, the head shaking nystagmus, the unilateral weakness of ct, and the gain,phase, and asymmetric parameters of SHAT were used as observation indicators to analyze the frequency characteristics of vestibular function damage in meniere's disease.
Results: The positive rate of CT, HSN and vHIT were 67.6%(25/37), 40.5%(15/37)and 24.3%(9/37)respectively. Comparation of the positive rate among CT, HST and vHIT showed statistically signifjcant difkrence(x2=10.93, P=0.001; x2=28.79, P=0.000). Comparation of the positive rate between HST and vHIT showed 8tatistically significant difkrence(x2=4.87, P=O.027).
The SHAT gain values were low in the range of 0.01∼0.3Hz, and showed high phase within the corresponding frequency range of low gain. Asymmetry also showed a bias towards the affected side.
Conclusions: Vestibular Function Damage in Meniere's disease patients mainly presents in the low frequency area, which indicates a characteristic phenomenon that low-ftequency function area is more predisposed to be involved than the middle-frequency fhnction area and the high-frequency fhnction area in Meniere disease patients.
PPI:64 - Hyper-response of cervical VEMP in patients with Meniere disease
Minbum Kim1, Soyeon Yoon1
1Department of Otorhinolaryngology, Catholic Kwandong University, International St. Mary's Hospital, KOREA
Purpose: The purpose of this study is to investigate the hyper-responsiveness of cervical vestibular-evoked myogenic potential (cVEMP) in patients with Meniere’s disease (MD), and to compare the result of cVEMP between probable and definite MD group.
Methods: A total of 110 patients satisfied with “Probable MD” and “Definite MD” criteria, which is recently formulated by the Classification Committee of the Bárány Society, were included. An inter-peak amplitude and interaural amplitude difference (IAD) ratio of both ears was measured. The abnormal response of ipsi-lesional cVEMP was categorized into two groups; “hyper-response” and “hypo-response”. Chi-square test and Mann-Whitney U test were used for statistical analysis.
Results: (1) In the “Probable MD” and “Definite MD” group, the mean IAD was 25.24±17.79% and 53.82±34.98% , respectively (p<0.01). (2) The abnormal response of cVEMP at the affected ear was more frequent in the “Definite MD” group, compared to the “Probable MD” group (32/40 vs. 13/36, p<0.01). (3) However, hyper-response was more frequently observed in the patients with “Probable MD” , compared to the patients with “Definite MD” (13/36 vs. 3/40, p<0.01).
Conclusions: Hyper-response of cVEMP was more frequently observed in the early “probable MD” patients. It might be an early sign of MD, related with the saccular hydrops, which can help the early detection and treatment.
PPI:66 - Intratympanic drug administration
Veronika Bandurova1, Marketa Bonaventurova1, Zuzana Balatkova1, Zdenek Cada2, Jan Plzak1
1Motol University Hospital, Department of otorinolaryngology and head and neck surgery, Czech republic
2Department of Ear,Nose and Throat , 2nd Medical Faculty
Purpose: Farmacoresistant Meniere´s disease is a very unpleasant, limiting condition, when patients do have attacks inspite of maximal doses of oral medication.
There are several ways how to help them: intravenous or intratympanic administration of drugs or surgery. We choose methods according to health status of the patient, our experience and technical equipment. Intratympanic administration is stated as safety procedure with a high succes rate in treatment. Goal of this study is to check efficacy of corticoid vs gentamicin administration, possible side effects or complications and to check our data with the literature.
Methods: Patients stated as farmacoresistant, examined in-between years 2018 and 2023 were enrolled in the study. Vestibular assesment was measured. Gentamicin was administered only in patients with non-serviceable hearing and in patient with intact contralateral inner ear function. They were observed in regular intervals, when number of attack was reffered, otomicroscopy was provided and vestibular examination was done.
Results: Both drugs are safe for intratympanic administration. Advantage of gentamicin is single administration. Disadvantages are risk of worsening of hearing loss and necessity of vestibular rehabilitation. Advantages of metylprednisolon is stable state without vestibular loss. Disadvantages are repeated administration and risk of persistant ear drum perforation.
Conclusions: Treatment of farmacoresistant Menire´s disease should be individualized. We do have many possilities even in farmacoresistant patients.
In case, when intratypmanic administration fails, we can offer patient more types of surgery. But one of the most important parts of treatment is still to take time for each patient and speak to them.
PPI:67 - Low Dose Intratympanic Gentamicin Injection for Intractable Meniere’s Disease: How Many Times Should We Repeat?
MIN-BEOM KIM1, JOON-PYO HONG2
1Department of Otorhinolaryngology-Head and Neck Surgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
2Department of Otorhinolaryngology-Head and Neck Surgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
Purpose: To assess ideal repetition times for low dose intratympanic gentamicin injection (ITGM) in intractable Meniere’s disease (MD)
Methods: Clinical charts of patients who were diagnosed with definite MD between 2015 and 2020 in our tertiary medical center and received ITGM for intractable vertigo attacks were reviewed. 33 patients of intractable MD were divided into single group (n=14) and multiple group (n=19) depending on the repetition times of low dose ITGM.
Results: Both the single and multiple groups showed prominent impairments in the vestibular test with an improvement in hearing after the initial ITGM. However, in the multiple group, a second ITGM was needed on average 8.1±6.4 months after the initial ITGM, due to the consistent vertigo attacks after the initial ITGM. No further impairments in the vestibular test was observed after the initial ITGM, with a progressive deterioration in hearing.
Conclusions: There were no reliable test results that could predict the success of low dose ITGM in treating intractable MD. Instead, the improvement in a patient's subjective vertigo symptoms after the first ITGM trial was crucial in determining the need for further ITGM treatment. Furthermore, administering the low-dose ITGM two or more times seemed to offer no additional benefits in managing intractable MD, only with progressive hearing deterioration.
PPI:68 - Meniere disease subtyping: the direction ofdiagnosis and treatment in the future
Sulin Zhang1, Jun Wang1, Zhaoqi Guo1, Jingyu Chen1, E Tian1
1Department of Otorhinolaryngology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan City, Hubei Province, P. R. China
Purpose: Meniere's disease (MD) is a chronic disorder of inner ear, characterized by audial and vestibular symptoms. It presents a great variability among patients in terms of clinical features, etiology, pathology, and response to the same therapy. It's challenging to diagnose and manage for its heterogeneity. Indeed, the consensus is reached that MD has subtypes. Identifying subtypes of MD is important for individualized therapy and further research.
Methods: In this review, we examined the heterogeneity of MD. We also included the valid subtyping solutions and updated data regarding the association among subtypes, disease progression, and management.
Results: MD is an etiologically multifactorial condition, and it might be a constellation of symptoms associated with endolymph hydrops, not a disease entity. So far, MD can be classified as distinct phenotypes and endotype, respectively based on symptoms, pathology, possible etiology, and co-existing condition. Patients in different subtypes present different clinical features and are suitable for different treatment. The identification of these subtypes will benefit both basic and clinical studies of MD, by helping achieve personalized therapy, accurate prognosis prediction and even disease screening in near future.
Conclusions: Therefore, MD subtyping is the emerging direction of diagnosis and treatment in the future.
PPI:70 - Potential application of hydrops MR imaging in Meniere’s disease and its variants
Yi-Ho Young1, Kao-Tsung Lin2
1Department of Otolaryngology, Far Eastern Memorial Hospital, New Taipei, Taiwan
2Department of Otolaryngology, National Taiwan University Hospital, Taipei, Taiwan
Purpose: Diagnostic dilemma between clinical Meniere’s disease and radiological endolymphatic hydrops (EH) has emerged since the introduction of hydrops MR imaging. The aim of this study is to explore the potential application of hydrops MRI on diagnosing the EH.
Methods: This review was developed from peer-reviewed articles published in those journals listed on journal of citation reports. The MEDLINE database of the US National Library of Medicine, Scopus, and Google Scholar were used to collect articles based on the guidelines for reporting reviews.
Results: Initially, 470 papers were retrieved from 1983 to 2023, and 80 relevant papers were ultimately selected. The sensitivity (69-92%) and specificity (78-96%) values varied from each laboratory for detecting EH via hydrops MRI, probably due to candidate selection and the grading system employed.
Conclusions: The application of hydrops MRI allows 1) differentiation between EH and sudden sensorineural hearing loss; 2) determination of the affected side of EH; and 3) confirmation of the diagnosis of EH concomitant with other disorders. Notably, not all differentials for EH can be visualized on MR images. One of the existing gaps to be filled is that updated hydrops MRI fails to identify distortion, i.e., rupture, collapse, fistula or fibrosis of the inner ear compartments, akin to what histopathological evidence can demonstrate. Hence, enhanced ultrahigh resolution of hydrops MR imaging is required for demonstrating fine structures of the inner ear compartments in the future.
PPI:71 - Recent advance in Meniere Disease: new findings, new perceive, new surgery approach
Lisheng Yu
1
1Peking University People's Hospital
Purpose: At present, the treatment for Meniere Disease(MD) was empirical due to its unclear pathological mechanism. In this study, we introduced a new surgery approach focusing on enlarging antrotomy simultaneously removing mastoid air cell maximization, evaluated its efficacy and presented the new perceive for MD.
Methods: we performed a prospective randomized clinical trial for comparing the efficacy of new surgery approach and endolymphatic sac surgery. The primary outcome was the rate of controlling vertigo. The second outcome were the rate of preserving hearing, alleviating aural fullness and tinnitus. Based on the surgical findings and microorganism in mastoid, we proposed a new hypothesis for MD pathomechanism.
Results: We found we found the mean frequency of vertigo attacks decreased from 2.28±3.92 to 1.04±2.77 in the past 6 months at the 2-year follow-up and from 2.28±3.92 to 0.90±1.24 in the past 6 months at the 5-year follow-up. The frequency of vertigo attacks over 6 months at baseline differed significantly (p=0.036), it also provided excellent accompanying symptom control, such as progressing hearing loss, tinnitus and aural fullness. And its efficacy was negatively associated with the stage of MD. In the total 120 MD patients receiving the new approach, no complications such as cerebrospinal fluid leakage, sigmoid sinus tearing and bleeding, facial paralysis, posterior semicircular canal injury and mortality appeared. we perceived that the obstruction of the secondary valva could increase anoxia of middle ear to aggravate furtherly endolymphatic hydrops.
Conclusions: The antrum entrance regulating the pressure and oxygen environment of the middle ear played a key role for the occurrence and development of MD. The new surgery approach aiming to enlarged the secondary valva with high efficacy and safety for `MD should be popularized.
PPI:72 - Recurrent vertigo due to Delayed Endolymphatics Hydrops supported by MRI findings
Chun Wai Yip1, Yew Meng Chan2
1National Neuroscience Institute , Singapore General Hospital, Department of Neurology , Singapore
2Singapore General Hospital, Department of Otolaryngology (ENT), Singapore
Purpose: Delayed endolymphatics hydrops (DEH) can present as monosymptomatic recurrent vertigo attacks in patients with a prior history of severe unilateral hearing impairment. We would like share our experience in diagnosing this mimic of recurrent vestibulopathy and vestibular migraine, by showing how contrasted MRI of the inner ear can help support the diagnosis in the appropriate clinical context.
Methods: Case reports.
Case 1
A 45 year old male with severe right sensorineural hearing loss and persistent tinnitus of unknown cause for 10 years duration, only developed recurrent vertigo about 3-4 times in the last 2 years. Each episode lasted about 30 minutes and was associated with increased tinnitus, nausea and vomiting . He had a history of infrequent migraine. The neuro-otological examination was normal except for right-sided hearing loss. The vHIT was normal, and calorics show 40 % weakness on the right.
Case 2
A 50 year old male was referred for recurrent vertigo. In 2019, he suffered left sided sudden onset sensorineural hearing loss of moderate severity, which did not recover after treatment. Four years later, he developed recurrent vertigo spells, lasting minutes to an hour. There was no associated headache or migraine history. The neuro-otological examination was normal except for left-sided hearing loss. The vHIT was normal, cVemps was asymmetrically reduced on the left , and calorics show 55 % weakness on the left.
Results: Intraveinous Gadolinium (GAD)-enchanced MRI of inner ear showed ipsilateral EH of the deaf ears in both cases.
Conclusions: Recurrent vertigo in patients with a prior history of severe hearing impairment can be a presentation of DEH. A high index of suspicion is needed to make the diagnosis. While this condition may be mimicked by vestibular migraine/ recurrent vestibulopathy, GAD-enhanced MRI will usually allow visualisation of EH of the ipsilateral deaf ear. However, the clinical context differentiates it from menieres' disease.
PPI:73 - Social Media Analysis of Meniere’s Disease: Insights and Challenges for Otolaryngologists
Brian McKinnon1, Nicholas Rossi1, Wilhelmina Tan1, Olivia Nixon1, Dayton Young1
1University of Texas Medical Center, Otolaryngology, United States
Purpose: The advent and growth of social media platforms have dramatically altered the landscape of health information sharing, particularly for conditions like Meniere's disease. This study delves into the nature and impact of shared experiences and peer support concerning Meniere's disease on social media, underscoring the critical need for analyzing this content for its influence and accuracy.
Methods: Employing a comprehensive qualitative approach, our study scrutinized social media posts from major platforms – Facebook, Instagram, and TikTok – over a period of three months. Key aspects of the analysis included authorship identification, examination of the subject matter, tone assessment, and evaluation of post popularity and engagement metrics. This methodology provided a nuanced understanding of the social media discourse surrounding Meniere's disease.
Results: A significant portion (75%) of the analyzed posts were predominantly image-driven, with a majority (60%) authored by patients or their family members. The content analysis revealed that personal experiences comprised 40% of the posts, followed by informational posts at 30%, and queries or advice-seeking posts at 20%. Among the platforms, Instagram was the most utilized for Meniere's disease discussions, making up 50% of the posts, with Facebook at 30%, and TikTok at 20%. Sentiment analysis showcased a diverse range of emotions: 45% of posts displayed a positive tone, 35% were neutral, and 20% expressed negative sentiments.
Conclusions: The findings from this study highlight a significant demand for accurate and authoritative educational resources on social media regarding Meniere's disease. They offer Otolaryngologists valuable insights into improving patient-centered care by developing and implementing effective, evidence-based communication strategies on these platforms. Emphasizing patient empowerment and engagement, these strategies should cater to a patient population that is increasingly turning to social media for health-related information and support. The study also points to the necessity of addressing misinformation and guiding patients towards reliable sources of medical information online.
PPI:74 - Study on targeted high-throughput sequencing susceptibility gene screening in 100 MD patients
Zhanguo Jin1, Lihong Zhai1
1Air Force Medical Center of Chinese PLA, Balance Disorders medical Center, China
Purpose: Study on targeted high-throughput sequencing susceptibility gene screening in 100 cases of Meniere's disease patients.
Methods: The LIST of MD candidate genes was determined by literature review, biological information database retrieval, and pathophysiological mechanism related targets. The patients with confirmed MD who were admitted to the ward of Air Force Medical Center and the healthy adults who were admitted to our hospital for health examination during the same period were included. The peripheral venous blood of the subjects was collected and their genomic DNA was extracted. High throughput sequencing of targeted MD candidate genes was performed through probe design, library construction, target capture, and computer sequencing. The above sequencing results were analyzed by Rpackage V4.3, and the mutant genes were secondary screened according to the pathogenic characteristics of MD and the expression sites and characteristics of the mutant genes.
Results: A total of 100 MD patients were included, and MD customized panel was made according to gene LIST. Based on high-throughput sequencing platform technology, we found missense mutations in MLIP gene on chromosome 6, and the mutation frequency in MD patients was significantly different from that in healthy controls (P < 0.05).
Conclusions: The discovery of MLIP mutation has enriched the mutation spectrum of MD gene and provided a new research direction and possible breakthrough point for the genetic study of MD, but its pathological molecular mechanism and its value in assisting the diagnosis of MD still need to be further studied.
PPI:75 - The Association of Functional Vision Head Impulse Test (fvHIT) in patients with Meneire’s Disease
Batoul Berri1, Michelle Petrak2, Elizabeth Fuemmeler2, Devin McCaslin1
1University of Michigan, Otolaryngology-Head and Neck Surgery/Audiology, USA
2Interacoustics A/S, Research, Denmark
Purpose: Ipsilesional abnormal caloric testing in the presence of normal video head impulse testing (vHIT) is a pattern of findings observed in patients who have Ménière's disease (MD). Although the vHIT provides critical information regarding the quantitative metrics of the vestibulo-ocular reflex, it does not provide functional information.
We report 5 patients with MD and describe how functional vision impulse test (fvHIT) may prove helpful in assessing how well an individual can resolve the characteristics of a stationary target. This project describes the associations between the fvHIT in patients with MD and varying degrees of vestibular impairment.
Methods: All patients were evaluated in a tertiary care medical center. Each patient underwent audiometry, videonystagmography, rotational chair test, video head impulse testing, and functional vision impulse test. The fvHIT assesses patient’s ability to determining the direction of an optotype during high frequency rotational accelerations (1000-7000 Hz).
Results: All 5 patients demonstrated normal vHIT velocity gain, significant caloric weaknesses, and poorer fvHIT performance. The ability to stabilize images on the fovea during unpredictable functional performance correlated with their uncompensated vestibulopathy. fvHIT scores fell below 80% across impulses.
Conclusions: fvHIT may provide important assessment tool to accurately manage the progression and functional impact of Ménière’s disease on patients. It has the advantages of being easy to administer and non-invasive.
PPI:76 - THE BASIC MECHANISM OF VERTIGO ATTACKS IN MENIERE'S DISEASE WITH EXPLANATORY ANIMATION
William Gibson1, Stephen Spring2
1The University of Sydney, Australia
2Visualisation, independent researcher, expert patient for medical advancement, Sydney, Australia
Purpose: The immuno-defence of delicate hair and supporting cells is critical as they do not regenerate in humans. The endolymphatic sac (ES) guards the inner ear and is immunologically competent. A mechanism has evolved to transport viruses, bacterial and otoconia remnants, dead cells and other noxious agents to the ES for processing ‘off site’ to protect hair cells from infection and overt inflammation. This active transport mechanism is longitudinal flow of endolymph. Recent studies suggest the ES, itself a source of endolymph, activates to increase endolymph volume and initiate longitudinal flow.
Methods: Examples will be shown of transtympanic electrocochleography during a severe attack, and the audiogram recorded during a severe attack.
Results: These findings show no change in the endocochlear potential and argue against a rupture of Reisner’s membrane or potassium leakage.
We suggest that in a hydropic ear with a restricted endolymphatic duct and/or dysfunctional ES, excess endolymph cannot flow to the ES sufficiently quickly enough when longitudinal flow is activated. As a result, the sinus, which normally acts as a reservoir, cannot contain all the excess endolymph and the valve of Bast opens and cochlear endolymph enters the utricle, stretching the cristae of the semicircular canals causing vertigo.
Conclusions: Following initial vertigo attacks in an ear setup with hydrops, small increases of endolymph due to factors such as diet, lifestyle and infection will present as a cluster of vertigo attacks until endolymph volume decreases sufficiently for remissions to occur. Vertigo by this mechanism provides an explanation for the multifactorial nature of hydropic inner ear disease, including immune activation.
PPII:118 - The effectiveness of intratympanic injections with methylprednisolone vs placebo in the treatment of Menières disease
Maud Boreel1, Babette van Esch1, Berber Mol1, Peter Paul van Benthem1, Tjasse Bruintjes1
1Leiden University Medical Center, Otorhinolaryngology, Head and Neck surgery, Netherlands
Purpose: Although previous research reveals the potential effectiveness of intratympanic methylprednisolone in Menière’s disease (MD), up till now, no placebo-controlled randomized controlled trial with methylprednisolone has been conducted. In this study, we aim to investigate the effectiveness of intratympanic injections of methylprednisolone on vertigo attacks in patients with MD.
Methods: In this multicenter, randomized double-blind, placebo-controlled trial, patients diagnosed with unilateral MD receive two intratympanic injections of methylprednisolone or placebo and are followed for 12 months to assess the frequency of their vertigo attacks. In addition, tinnitus, hearing loss, quality of life, and cost-effectiveness are evaluated during the follow-up period.
Adult patients diagnosed with unilateral, definite MD, who have experienced at least four vertigo attacks in the past six months, are eligible to participate. Those who have received intratympanic corticosteroid injections in the previous six months, those who have ever received intratympanic injections with gentamicin and those who have undergone ear surgery for MD, will be excluded from the study. A total of 148 patients will be recruited from six centers throughout the Netherlands.
Results: The study officially started on October 10th2023, and multiple patients have been included so far. Since the inclusion is not yet complete, results will follow.
Conclusions: This is an introduction to a clinical trial on the effectiveness of intratympanic injections with methylprednisolone in patients with MD.
18. Spatial Orientation
PPI:88 - Clinic friendly spatial orientation testing has high test-retest reliability
Cesar Arduino1, Brooke Klatt2, Benjamin Crane1, Eric Anson1
1University of Rochester, Otolaryngology, USA
2University of Pittsburg, Physical Therapy, USA
Purpose: The vestibular system contributes to spatial orientation, and individuals with bilaterally reduced or absent vestibular function demonstrate worse performance on spatial orientation tasks than healthy individuals. In contrast to spatial orientation updating, there are no valid or reliable clinical assessments of spatial orientation perception. Spatial orientation perception is not restricted to world fixed scenarios and affords opportunities to examine self-motion perception in the context of rotary space. We hypothesize that spatial orientation is reliable in healthy adults.
Methods: Fifty-three healthy adults (mean age 25.4 SD 10.6 years) participated in a spatial orientation perception test and a subset completed a second test 1-2 weeks later (n = 31). Blindfolded and seated subjects were rotated 16 times right or left with displacements of 120, 150, 210, or 240 degrees. Verbal responses corresponding to the “hour position on a clock” were recorded. No feedback was ever provided regarding accuracy to prevent spatial updating or error-based learning. Test-retest reliability was determined using intraclass correlation coefficients.
Results: Average spatial errors were 40.8 (SD 19.9) degrees at the first visit and 36.2 (SD 17.0) degrees on the second visit. The intraclass correlation coefficient for absolute agreement was 0.72 (95% Confidence Interval 0.41-0.87) and was significant (F(30.0, 30.0) = 3.49, p = 0.001).
Conclusions: Healthy adults are accurate to approximately 1 “clock hour position” when using an analog clock frame of reference to judge where their rotation stopped (always starting from 12). Larger errors in spatial orientation perception compared to previous studies examining spatial orientation updating likely reflect the absence of feedback, limiting opportunities for error-based learning. Spatial orientation ability in healthy adults was highly reliable across visits in the short term. This low-tech clinic friendly method of examining spatial orientation perception appears to have sufficient reliability for clinical use, future studies are needed to evaluate discriminative ability.
PPI:89 - Effect of accuracy of virtual sound source location perception on Semicircular Ocular reflex
Yumiko O. Kato1, Yoshiyuki Sasano1, Shuichi Sakamoto2, Izumi Koizuka1, Manabu Komori1
1St. Marianna University School of Medicine Department of Otolaryngology
2Tohoku University Research Institute of Electrical Communication
Purpose: We are investigating the effect of localization accuracy on the semicircular ocular reflex (ScOR) for effective multi-modal vestibular rehabilitation. In the present study, we are evaluating the effect of perceptual accuracy of virtual sound source on the ScOR.
Methods: Four healthy adults participated. Experiment 1 assessed accuracy in perceiving virtual sound source direction. Experiment 2, horizontal eye movements were recorded using video-oculography during chair and sound source rotation. The chair rotated at 0.32Hz with a 30-degree amplitude. Sound source rotation conditions involved opposite, same, and no chair rotation directions. Each condition included sound source rotation at the same or twice the chair amplitude. Both front and rear sound sources were examined. Eye movement gains to chair and sound source rotation were analyzed.
Results: In condition where both the chair and sound source were rotated, ScOR gains increased in two subjects, remained unchanged in one, and decreased in the other, for both the front and rear sound source. The subject exhibiting a decrease in gain, exhibited poorer accuracy in sound localization. In condition where only the sound source was rotated, some subjects showed synchronized eye movements with sound source rotation.
Conclusions: Similar results in both front and rear sound sources suggest the potential effectiveness of surround sound images in vestibular rehabilitation. Variations in the ability to localize sound sources may result in differences in effectiveness among individuals in auditory vestibular rehabilitation.
This study is supported by JSPS KAKENHI Grant Numbers JP19K12088 and JP22K12119.
PPI:90 - Getting lost after stroke: a systematic review on the prevalence and assessment of post-stroke navigation
Joyce Bosmans1, Julie Moyaert2, Julie Van Eetvelde3, Céline Gillebert1
1Department of Brain and Cognition, Leuven Brain Institute, KU Leuven, Leuven, Belgium
2Department of Translational Neurosciences, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
3Department of Rehabilitation Sciences and Physiotherapy, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
Purpose: Navigation, the ability to find your way from one place to another, is an important cognitive skill to live an autonomous daily life. Several findings indicate that navigational ability can be impaired after stroke. However, navigation is rarely assessed in clinical practice. Furthermore, an accurate estimation of the prevalence of post-stroke navigational impairments together with the application of suitable neuropsychological assessment tools have been lacking in the scientific literature. The systematic review aims to determine the prevalence of post-stroke navigational difficulties. In addition, an overview of the tools to assess navigational difficulties after stroke, including their strengths and limitations, will be provided based on case and group studies.
Methods: A systematic literature review and meta-analysis.
Results: The pooled effect size using a fixed-effect model including data from a subset of 7 out of the 31 included studies determined a prevalence of general navigational impairments post-stroke of 30% (95% CI: 0.27 – 0.34). The Wayfinding Questionnaire is recommended to be used as a validated screening instrument for subjective navigation-related complaints after stroke. If indicated, an extensive objective navigation test such as the Virtual Tübingen test can be administered.
Conclusions: Navigational difficulties may be more common post-stroke than previously thought. The inclusion of subjective and objective neuropsychological assessments of navigation is recommended in clinical practice. However, the underlying mechanisms of navigational complaints are not well understood yet. Future research could evaluate navigation in people with vestibular versus brain injury to disentangle the impact of the inner ear versus the brain on navigation.
PPI:91 - Impacts of hypoxia in a case of adapted unilateral vestibulopathy
John Oas1, Daniel Merfeld2, Max Teaford3, Zachary Mularczyk1, Cora Cox1, Kyle Pettijohn1
1Naval Medical Research Unit Dayton, Naval Aerospace Medical Research Laboratory, United States
2The Ohio State University, Department of Otolaryngology and Naval Medical Research Unit Dayton, Naval Aerospace Medical Research Laboratory, United States
3University of Tennessee at Chattanooga, Department of Psychology, United States
Purpose: A case report to evaluate the impact of hypoxia on compensated peripheral vestibulopathy.
Methods: A 41-year-old man with acute vestibular syndrome (acute onset imbalance with nausea and vomiting) diagnosed (negative brain MRI and +cold-calorics) 6 years prior to testing. We used a standard forced-choice psychophysical method to quantify earth-vertical translation thresholds collected at an elevation of 823', and controlled breathing air oxygen (O2) content of 20.9%, 16.6%, and 15.4%, chosen to simulate O2 content found at altitudes of 0', 6000' and 8,000', using a Reduced Oxygen Breathing Device. We asked a series of questions querying vestibular symptoms before and after each of four trials at altitude and compared these to baseline responses. He also underwent 6-direction video head impulse testing (vHIT).
Results: The median earth-vertical translation thresholds were 18%-21% greater when the O2 content was 16.6% or 15.4%, respectively, which mimics increases found in healthy subjects. He reported spatial disorientation, perceptual illusions of forward tilt, and motion sickness symptoms at both altitudes; this contrasts with reports from healthy subjects who reported no symptoms – even when asked. Video head impulse testing (vHIT) was symmetrically within normal limits.
Conclusions: These results suggest that vestibular symptoms can manifest at simulated altitudes of 6,000'-8,000'. Patients with compensated unilateral vestibulopathies who travel by commercial jet may experience spatial disorientation and perceptual illusions on top of degraded vestibular function due to the mild hypoxia. The source of this decompensation remains elusive as both vestibular end organs and central vestibular pathways might be involved.
PPI:92 - Precision and Test-retest Reliability of Supra-threshold Magnitude Estimates in the Yaw Axis
Hannah Martin1, Erin Hernon1, Erin G. Piker2, Kristal Riska1
1Duke University Department of Head and Neck Surgery and Communication Sciences
2James Madison University, United States
Purpose: The purpose of this study is to evaluate precision and test-retest reliability for a supra-threshold vestibular perception task testing spatial orientation in adults.
Methods: Healthy adults over the age of 60 years with (n = 10) or without (n = 11) a fall in the last year underwent a series of psychophysical measurements aimed at understanding their perception of spatial orientation about the yaw axis using a commercially available rotary chair. Using frequencies between 0.08 - 0.64 Hz at velocities ranging from 30 - 90 degrees per second, individuals were asked to rate their maximum displacement. Visual and auditory input were eliminated via vision-denied goggles and broadband noise via headphones. Data demonstrating test-retest reliability at 0.24 Hz at 60 degrees per second is presented herein.
Results: A total of 21 subjects have been tested, with ongoing enrollment and plan for total of 30 subjects. To date, the mean age is 74 (range 68 - 81 years) with 11 female and 10 male individuals. For trial one, 40% of fallers and 27% of non-fallers reported displacement values within 10 degrees of the actual displacement magnitude. Using data obtained from both trial 1 and trial 2, we will calculate intra-class correlation coefficients using a 2-way mixed-effects model to assess within-session test-retest reliability.
Conclusions: Preliminary results suggest variation in accuracy of spatial orientation estimates in this cohort of adults over 60 years. Ongoing work will examine within-session test-retest reliability.
PPI:93 - Research on evaluation of pilot’s spatial cognition ability based on virtual reality
Zhanguo Jin1, Mengdi Zhang1
1Air Force Medical Center of Chinese PLA, Balance Disorders medical Center, China
Purpose: To investigate effectiveness of mental rotation test and maze test based on virtual reality in predicting pilots’ visualization ability and orientation ability.
Methods: According to scale's score, 118 pilots were divided into high, middle or low spatial ability group pursuant 27% allocation principle. Differences in reaction time, correct rate and correct number per second of mental rotation test and spatial orientation test between groups were compared. Reaction time, correct rate and correct number per second of the two tests among different age groups and between genders were also compared.
Results: Reaction time of high spatial ability group was remarkably slower than low spatial ability group(Z=22.03, P=0.030). Correct number per second of high spatial ability group was dramatically higher than low spatial ability group(Z=-21.05, P=0.042). Pilots in 29∼35 year old age group had considerably slower RT than those in 22∼28 year old age group(Z=26.28, P=0.013). Pilots in 29∼35 year old age group had conspicuously higher CNPS than pilots in 22∼28 year old age group(Z=-22.74, P=0.042). Reaction time of low spatial ability group was remarkably higher than high and middle spatial ability group(Z=-2.021, P=0.043; Z=-2.410, P=0.016). Pilots in 22∼28 years old age group had considerably slower reaction time than those in 29∼35 years old and more than 35 years old age group(Z=-2.495, P=0.013; Z=-2.158, P=0.031). Pilots with more than 2000 hours of flight time had significantly higher reaction time than those with less than 1000 hours and 1000∼2000 hours of flight time(Z=-2.741,P=0.006;Z=-2.388, P=0.017). Pilots’ scale scores were negatively correlated with their reaction time (r=-0.195, P=0.028).
Conclusions: This study combines virtual reality with traditional spatial visualization test and spatial orientation test to establishes an experimental method for spatial cognition test based on virtual reality technology.
PPI:94 - Spatial anxiety and perspective-taking contribution to the handicap related to peripheral vestibular disease
KATHRINE JAUREGUI-RENAUD1, DULCE MARIA GARCIA-JACUINDE2, SIMON PEDRO BARCENAS-OLVERA2, MICHAEL GRESTY3, ARALIA GUTIERREZ-MARQUEZ2
1Instituto Mexicano del Seguro Social, Unidad de Investigación Médica en Otoneurología, México
2Instituto Mexicano del Seguro Social, HG Centro Médico Nacional “La Raza,” México
3Imperial College London, Division of Brain Sciences, United Kingdom
Purpose: To assess the combined contribution of spatial anxiety, spatial perspective-taking, and individual cofactors (including stress) to the dizziness-related handicap reported by patients with peripheral vestibular disease and controls.
Methods: 153 adults with and 156 adults without peripheral vestibular disease accepted to participate in the study, including patients with unilateral deficiency (evolution <3 or ≥3 months), bilateral deficiency, Meniere’s disease, and Benign Paroxysmal Positional Vertigo. Evaluations comprised: general health and personal habits (including sleep), spatial anxiety, spatial perspective-taking, the dizziness-related handicap inventory (DHI), perceived stress, unsteadiness, motion sickness susceptibility, trait anxiety/depression, state anxiety, and depersonalization/ derealization symptoms. Bivariate and covariance analyses were performed with a significance level of p≤0.05.
Results: The spatial anxiety score was related to the report of unsteadiness and perceived stress, and it was inversely related to trait anxiety (ANCoVA, p<0.00001). The variability on perspective-taking was related to vestibular disease, trait and state anxiety, motion sickness susceptibility, and age (ANCoVA, p<0.00001). The three domains of spatial anxiety contributed to the Physical domain of the DHI, while the Navigation domain contributed to the Functional domain. The variability on the DHI was also related to unsteadiness, perspective-taking, sleep quality, and trait anxiety/depression (ANCoVA, p<0.00001).
Conclusions: Spatial anxiety was related to perceived stress, and it was also inversely related to trait anxiety. We propose that state anxiety and acute stress could be helpful for recovery after an acute peripheral vestibular lesion; subsequently, spatial anxiety and perspective-taking may contribute to dizziness-related handicap, possibly because it discourages behavior beneficial to adaptation.
PPI:95 - The influence of gaze direction on motion perception in the oculogyral illusion (OGI)
Maria Luiza di Carlo Riato1, Jeroen Smeets1, Constanza Fuentealba-Bassaletti2, Tjasse Bruintjes2, Jelte Bos1
1Department of Human Movement Sciences, Faculty of Behavioral and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
2Department of Otorhinolaryngology and Head and Neck Surgery, Leiden University Medical Center, Leiden, The Netherlands
Purpose: Oculogyral illusion (OGI) is the perceived drift of a head-fixed target during self-rotation in healthy individuals. This phenomenon is caused by a mismatch between predicted visual input and vestibular signals. An OGI theoretical model suggests that semicircular canals generate an opposite efference copy for sensed angular motion, proposing that target position can influence the OGI. Prior research linked OGI to the after-image drift in Meniere's disease patients during the Extended Utermohlen Test (EUT), with optimal prisms reducing drift. Underlying theory remains invalidated.
Aim: To assess gaze direction's influence on motion perception during the OGI and validate the prediction by exposing subjects to angular motion.
Methods: Twenty-two healthy subjects, aged 18 and above, of both sexes, without previous history of vestibular disorders, sat in a rotatory chair in a dark room while wearing VR goggles displaying a fixation target at a virtual distance of 2 meters. The target was initially centered, then displaced 10° to the right and left in separate trials. Participants indicated the apparent target drift (ATD) direction in a two-alternative forced choice task. Collected data was pooled across subjects and time stamps, averaging across different trial phases. Analysis involved statistically comparing ratings between acceleration and deceleration periods to assess the effects of target displacement and gaze control. Error bars were calculated using the standard error of the mean (SEM).
Results: Mean ATD during acceleration and deceleration were statistically different than 0 (p=<0.05). ATD matches motion direction during acceleration and opposes it during deceleration. Target displacement significantly influenced ATD ratings. ATD was reduced when the displacement was opposite to the sensed motion (p=<0.05).
Conclusions: OGI was successfully elicited using virtual reality. Decreased apparent target drift when actual displacement is opposite to the sensed motion suggests that gaze control influences subjects' target motion perception.
PPI:96 - Vestibular rotation cancellation perception by vision in patients with increased visual dependency
Vergil V Mavrodiev1, Christopher J Bockisch1, Konrad P Weber2, Fabienne C Fierz3
1Department of Neurology, University Hospital Zurich, Switzerland
2Department of Neurology and Department of Ophthalmology, University Hospital Zurich, Switzerland
3Department of Ophthalmology, University Hospital Zurich, Switzerland
Purpose: Our goal was to investigate differences in patients with visual dependancy compared to healthy controls utilizing perceptual measures of self-movement in situations where visual motion and vestibular signals give conflicting information.
Methods: Recruitment was conducted at the outpatient clinic of the University Hospital Zurich. Prospective data was collected from 25 healthy individuals as well as 21 subjects with increased visual dependency. Subjects were passively rotated in space and exposed to visual stimulation that conflicted with the actual motion and the motion sensed by the vestibular system. Subjects indicated their perceived direction of self-motion. We measured how long it takes for the perception of self-motion, initially dominated by vestibular signals, to transition into being dominated by visual signals. This was carried out by a rotating chair, moving independently of a patterned drum around the chair. Runs with various conditions were performed - movement of the chair in darkness, movement of the chair and the drum with the same speed with lights on (cancellation trial) as well as movement of the chair and drum in the same direction but with different speeds with lights on (reverse trial).
Results: In normal movement trials in darkness without visual stimuli, healthy subjects perceived the vestibular rotation for about around 10.9 seconds on average while the duration was 11.2 seconds for subjects with an increased visual dependency. The visual stimuli reduce the duration of perceived rotation to 7.7 and 4 seconds in the cancellation and reversal trials, respectively for healthy subjects, and to 7.7 and 4.3 seconds for individuals with an increased visual dependancy.
Conclusions: On average, patients with visual dependency did not show greater reliance on visual cues when visual and vestibular self-motion stimuli conflict. We could not measure a quantifiable difference in the perception of movement when putting the vestibular and the visual systems in conflict.
23. Vestibular Compensation and Rehabilitation
PPII:18 - A Collaborative Approach to Chronic Dizziness - The Utah Chronic Dizziness Collaborative (UCDC) and Dizzy School
Judith Warner1, Janene Holmberg2, Neil Patel3, Meagan Seay1, Richard Gurgel3, Kathleen Digre1
1Department of Ophthalmology and Vision Sciences, Department of Neurology, University of Utah, USA
2Intermountain Hearing and Balance Center, Utah, USA
3Department of Otolaryngology, University of Utah, USA
Purpose: Dizziness is a common complaint, accounting for 5.6 million clinic visits in the U.S. yearly. Up to 30% of cases develop chronic dizziness or Persistent Postural-Perceptual Dizziness (3PD). 3PD is a medical condition defined by a persistent feeling of dizziness or unsteadiness following a triggering event. Although vestibular testing is often non-explanatory, there is growing definable pathophysiology related to maladaptation of central networks responsible for space/motion perception. Sufferers often see multiple physicians, undergo costly inconclusive tests, ineffective rehabilitation, and experience suboptimal outcomes. The Utah Chronic Dizziness Collaborative (UCDC) was established in 2021 to develop a multidisciplinary approach to evaluation and treatment.
Methods: UCDC held monthly virtual meetings from 2021-2023 with vestibular therapists, audiologists, physicians, psychologists, and a wellness coach. UCDC consulted with experts in the field of dizziness and 3PD as invited speakers. We reviewed literature regarding chronic dizziness to determine how to effectively evaluate and treat patients. The literature review was synthesized into quality of evidence tables and best practice recommendations were made.
Results: The consensus of the UCDC was that patients referred for chronic dizziness should undergo screening for medical conditions by referring providers, and if indicated have evaluation with vestibular testing. Co-morbid vestibular and neurologic disorders should be sought, including vestibular migraine. A patient and provider website entitled “Dizzy School” was created. In the 6 months after inception, the site had received 11,369 visits from 7,514 individuals.
Conclusions: The UCDC concluded that a comprehensive approach to chronic dizziness would benefit patients and providers alike. Based on available evidence regarding 3PD, UCDC recommended (1) customized vestibular rehabilitation with physical therapists, (2) low dose serotonin-based medication, and (3) cognitive behavioral therapy. To promote patient and provider education, we created the Dizzy School website. The UCDC is currently working on dissemination of this approach through local, national, and international meetings and workshops. https://medicine.utah.edu/neurology/education/dizzy-school.
PPII:19 - Central vestibular dysfunction: don't forget vestibular rehabilitation
Sulin Zhang1, Dan Liu1, Jun Wang1, E Tian1, Zhaoqi Guo1, Weijia Kong1
1Department of Otorhinolaryngology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan City, Hubei Province, P. R. China
Purpose: Vestibular rehabilitation (VR) is now a subject of active studies and has been shown to be effective for multiple vestibular disorders, peripheral or central. VR is a physical therapy that helps train the central nervous system to compensate for vestibular dysfunction. There is moderate to strong evidence that VR is safe and effective for the management of peripheral vestibular dysfunction. Nonetheless, the studies on how VR works on central vestibular dysfunction remains scanty.
Methods: This article addressed the rehabilitation strategies and possible mechanisms, including how central vestibular function might improve upon rehabilitation. In addition, it provides some examples concerning the effect of VR on central vestibular dysfunction.
Results: VR works on the vestibular system through repetition of specific physical exercises that activate central neuroplastic mechanisms to achieve adaptive compensation of the impaired functions. VR has become a mainstay in the management of patients with dizziness and balance dysfunction. Individualized VR programs are a safe and effective treatment option for a large percentage of patients with central vestibular disease reporting imbalance and dizziness.
Conclusions: Exploration of various treatment strategies and possible mechanisms will help develop the best and personalized VR treatment for patients with central vestibular dysfunction.
PPII:20 - Changes in Spontaneous Cortical Brain Activity in Patients with Chronic Unilateral Peripheral Vestibular Dysfunction
Kangzhi Li1, Xia Ling2, Lihong Si3, Yue Xing3, Yuru Wang3, Jianrong Wang3, Yuan Xu3, Siru Xue3, Xu Yang3
1Peking University Shougang Hospital, Department of Neurology, China
2Peking University First Hospital, Department of Neurology, China
3Peking University Aerospace School of Clinical Medicine (Aerospace Center Hospital), Department of Neurology, China
Purpose: To explore changes in spontaneous cortical functional activity in patients with chronic UPVD and elucidate the neural basis of poor dynamic compensation in UPVD patients.
Methods: Patients with chronic UPVD who visited our hospital were included, and vestibular function tests were performed to assess baseline characteristics of the patients. Further, resting-state fMRI was conducted to evaluate voxel-mirrored homotopic connectivity (VMHC) to assess changes in bilateral cortical functional activity symmetry, and additional indices such as Amplitude of Low-Frequency Fluctuation (ALFF), Regional Homogeneity (ReHo), and degree centrality (DC), were calculated to evaluate cortical functional activity abnormalities from different functional perspectives.
Results: Twenty-two UPVD patients (10 cases of left UPVD and 12 cases of right UPVD) were included. VMHC analysis showed significantly decreased VMHC in the bilateral cuneus, precuneus, precentral gyrus, cerebellum in chronic UPVD patients. ALFF in the brainstem, including bilateral vestibular nuclei, were significantly decreased. ReHo in the left precuneus, postcentral gyrus, precentral gyrus, premotor area were significantly decreased. DC in the left occipital lobe, precentral gyrus, postcentral gyrus, and right cerebellar were significantly decreased in UPVD patients (All passed FDR correction, P<0.05). Correlation analysis indicated that changes in brain function of precuneus, precentral gyrus and postcentral gyrus were negatively correlated with DHI scores.
Conclusions: Abnormalities in the functional activity of multisensory integration and sensorimotor integration-related brain areas such as the precuneus, precentral gyrus, and postcentral gyrus may be underlying causes of dizziness and postural instability in UPVD patients.
PPII:21 - Changes of Dynamic Intrinsic Brain Function and Dynamic Concordance in Chronic UPVD Patients
Kangzhi Li1, Xia Ling2, Lihong Si3, Yue Xing3, Yuru Wang3, Jianrong Wang3, Yuan Xu3, Siru Xue3, Xu Yang3
1Peking University Shougang Hospital, Department of Neurology, China
2Peking University First Hospital, Department of Neurology, China
3Peking University Aerospace School of Clinical Medicine (Aerospace Center Hospital), Department of Neurology, China
Purpose: To explore changes in dynamic temporal patterns of brain intrinsic function and dynamic concordance among different indices in patients with chronic UPVD.
Methods: Patients with chronic UPVD who visited our hospital were included. Patients with chronic UPVD who visited our hospital were included and underwent vestibular function tests to assess baseline characteristics. Subsequently, resting-state fMRI evaluations were conducted. Following data preprocessing, sliding window analysis was performed to calculate the Amplitude of Low-Frequency Fluctuation (ALFF), Regional Homogeneity (ReHo), and degree centrality (DC) voxel-wise in different time windows. The coefficient of variation of corresponding indicators in different time windows was computed, resulting in dynamic ALFF, dynamic ReHo and dynamic DC. Furthermore, Kendall's coefficient of concordance was calculated voxel-wise for the three indicators in different time windows to explore dynamic consistency changes in different functional indicators in patients with chronic UPVD.
Results: Twenty-two UPVD patients were included. Dynamic analysis showed significantly decreased dynamic ALFF in the left occipital lobe of UPVD patients; significantly increased dynamic ReHo in the right postcentral gyrus and precuneus were seen in UPVD patients; and dynamic DC in the left inferior temporal gyrus and insula were significantly decreased. Concordance analysis showed a significant decrease of concordance in the bilateral cuneus, precuneus, postcentral gyrus, cerebellum, MT/V5 area, and frontal insula of patients with chronic UPVD.
Conclusions: Changes in temporal dynamic patterns of brain function and dynamic concordance among different indicators occur in patients with chronic UPVD, which may be important features of abnormal brain function in these patients.
PPII:22 - Chronic UPVD Patients still show Abnormality in Vestibular Nuclei-Cortex Pathway After Static Compensation Established
Kangzhi Li1, Xia Ling2, Lihong Si3, Yue Xing3, Yuru Wang3, Jianrong Wang3, Yuan Xu3, Siru Xue3, Xu Yang3
1Peking University Shougang Hospital, Department of Neurology, China
2Peking University First Hospital, Department of Neurology, China
3Peking University Aerospace School of Clinical Medicine (Aerospace Center Hospital), Department of Neurology, China
Purpose: To explore the changes in functional activity of the brainstem and the vestibular nuclei-thalamus/cortex pathway in patients with chronic UPVD.
Methods: Chronic UPVD patients treated at our hospital were included and vestibular function tests were conducted to assess baseline characteristics of the patients. resting-state fMRI were further conducted, calculating the voxel-mirrored homotopic connectivity (VMHC) to assess the symmetry of bilateral brainstem functional activity. Additionally, the Amplitude of Low-Frequency Fluctuation (ALFF) was calculated to explore changes in the intensity of spontaneous functional activity of the brainstem. Finally, seed-based functional connectivity was used to assess changes in the vestibular nuclear-thalamus/cortex pathway in UPVD patients.
Results: Twenty-two UPVD patients (10 cases of left UPVD and 12 cases of right UPVD) were included, with an average CP value of 58.25 ± 27.23% and an average DHI score of 39.17 ± 6.37 points. VMHC analysis showed no significant differences in the symmetry of bilateral brainstem and thalamic activity; ALFF analysis indicated a significant decrease in the ALFF of the brainstem including the vestibular nuclei. Seed-based functional connectivity analysis showed reduced functional connectivity from vestibular nucleus to thalamus, visual cortex, precuneus, postcentral gyrus, precentral gyrus, and premotor area. Correlation analysis showed a negative correlation between the ALFF value of vestibular nuclei and DHI scores.
Conclusions: Chronic UPVD patients still exhibit vestibular nucleus-thalamic/cortex pathway functional activity abnormalities after static compensation is established, which may be related to poor compensation in patients.
PPII:23 - Clinical indicators evaluate treatment efficacy in short-term personalized rehabilitation for vestibular vertigo
Jing Wang1, Jinyu Wang1, Yibo Lei2, Liang Tian1
1Eye Ear Nose & Throat Hospital, Fudan University, Department of otology, China
2Otolaryngology Hospital, The First Affiliated Hospital, Zhengzhou University, Department of otology, China
Purpose: Short-term personalized vestibular rehabilitation (ST-PVR) can establish stable vestibular compensation. However, there is a lack of a clear definition for clinical indicators that can dynamically reflect the progress of vestibular rehabilitation (VR).This study aimed to explore the clinical indicators suitable for evaluating the effectiveness of ST-PVR in treating benign recurrent vertigo (BRV).
Methods: In total, 50 patients diagnosed with BRV were enrolled. All patients received the ST-PVR treatment program. At 2 and 4 weeks after rehabilitation, subjective scales, including the visual analogue scale (VAS), dizziness handicap inventory scale (DHI), activities‐specific balance confidence scale (ABC) and the generalized anxiety disorder (GAD-7) were assessed. Objective vestibular function tests were performed. VR grading was determined.
Results: At two-week after rehabilitation, significant enhancements were observed in VAS, DHI, ABC, GAD-7, UW, vHIT results, and VR grading scores (p<0.05). The sensory organization test (SOT) results demonstrated statistically significant improvements at two-week and four-week after rehabilitation (p<0.05).
Conclusions: Both subjective scales and partial examination results in objective assessment can serve as indicators to dynamically monitor the compensatory process of vestibular function in patients with BRV. The VR efficacy grading score, which incorporates the above indicators, allows for quantification of the changes that occur during the vestibular rehabilitation process.
PPII:24 - Does cognition improve following participation in vestibular rehabilitation?
Brooke N. Klatt1, Eric R. Anson2, Yuri Agrawal3
1University of Pittsburgh, Department of Physical Therapy, USA
2University of Rochester, Department of Otolaryngology, USA
3University of Colorado, Department of Otolaryngology - Head & Neck Surgery, USA
Purpose: Compared to healthy controls, individuals with unilateral vestibular hypofunction (UVH) demonstrate impaired gaze stability, balance, and cognition (attention, executive function, memory, and visual spatial ability). Vestibular rehabilitation improves gaze stability and balance, but little is known about whether cognitive changes are observed following participation in vestibular rehabilitation.
Methods: Eight people with unilateral vestibular hypofunction (3 females; mean age 66.1 ± 10.5 years) completed neurocognitive assessment prior to and following participation in vestibular rehabilitation. Assessments included the Montreal Cognitive Assessment (MoCA), Money Road Map Test (MRMT), Trails Making Test (TMT) A and B, Forward and Backward Digit Substitution (FDS/BDS), Digit Symbol Substitution Test (DST), Benton Visual Retention Test (BVRT), and Santa Barbara Sense of Direction (SBSOD) test.
Results: There were not any statistically significant or clinically meaningful changes in the cognitive assessments following participation in vestibular rehabilitation. The following pre- to post-VPT mean differences were observed: MoCA = 1.00±2.83 (p=0.82); MRT errors = 2.00±5.01 (p=0.85); TMT A = 9.03±20.85 (p=0.87); TMT B = 28.91±71.86 (p=0.15); FDS = 0.63±1.19 (p=0.09); BDS = 1.00±1.85 (p=0.09); DSST = 1.38±7.33 (p=0.31); and BVRT = 0.88±1.64 (p=0.09). The sample demonstrated variability in baseline cognition with a wide range of scores for the MoCA (18-29/30), MRT errors (0-7), TMT A (17.91-59.45 sec), TMT B (30.81-523.76 sec), FDS (8-14), BDS (4-14), DSST (10-55), and BVRT (2-8).
Conclusions: In this small sample, individuals with UVH displayed persistent cognitive impairments after completion of vestibular rehabilitation. Future research is needed to determine how clinicians might be able to optimize cognitive abilities to augment vestibular rehabilitation efforts.
PPII:25 - Does the delay in starting vestibular rehabilitation influence the outcome?
Alejo Suarez1, Pilar Michelini1, Magdalena Vazquez1, Sofia Arocena1, Teresa Arocena1, Ana De Castellet1, Estela Pagano1
1Laboratorio de Otoneurologia, Montevideo, Uruguay
Purpose: Vestibular rehabilitation is a therapeutic option with strong evidence for improving symptoms caused by pathologies that lead to unilateral peripheral vestibular deficit, among other conditions. It has been proposed that the timeliness of intervention relative to the onset of symptoms is a key factor in the outcomes that can be achieved, particularly in functional measures. The purpose of this work is to assess whether the delay in starting vestibular rehabilitation in patients diagnosed with unilateral vestibular neuritis affects the perceived benefit by the patient.
Methods: A prospective study was conducted from 2019 to 2023 on 34 patients diagnosed with unilateral vestibular neuritis with a deficit of the vestibulo-ocular reflex sequel, who were referred for vestibular rehabilitation treatment. They were divided according to the start of treatment and the time since the onset of symptoms into 3 groups: G1≤30 days (n=12), G2 30-90 days (n=8), and G3≥90 days (n=14). The vestibular rehabilitation protocol consisted of weekly 30 minutes training sessions in an outpatient clinic accompanied by a home exercise program three times daily.The DHI score was measured at the beginning and end of the treatment, comparing the variation between groups.
Results: In all three groups, an improvement in the DHI score was observed, and no difference was noted in the variation of the score between the groups.
Conclusions: In the sample analyzed, the benefit perceived by the patient from the treatment received was not influenced by the delay in its initiation.
PPII:26 - Effects of sensory substitution therapy for patients with unilateral vestibular disorders
Sho Takaoka1, Go Sato1, Kazunori Matsuda1, Miki Tomura1, Yoshirou Wada2, Tadashi Kitahara2, Noriaki Takeda1, Yoshiaki Kitamura1
1Tokushima University Graduate School of Biomedical Science, Department of Otolaryngology-Head and Neck surgery, Japan
2Nara Medical University, Department of Otolaryngology-Head and Neck surgery, Japan
Purpose: We examined effects of sensory substitution therapy using TPAD for the patients with refractory unilateral vestibular disorders.
Methods: We have developed a new wearable sensory substitution device, Tilt Perception Adjustment Device (TPAD). TPAD transmits vibratory input containing head-tilt information to the mandible in substitution for defective vestibular information. We administered therapy to ten patients with refractory unilateral vestibular disorders, conducting the training at least twice a day for more than 20 minutes over a three-month period. We assessed the dizziness handicaps inventory (DHI), the CoP of posturography, and performed gait analysis using the motion capture system in this study.
Results: Total score of DHI was significantly improved after the vestibular rehabilitation using TPAD in patients with refractory unilateral vestibular disorders. The Romberg’s ratio of the velocity with foam rubber significantly decreased after the vestibular rehabilitation using TPAD. There was no significant difference between the foam ratio of the velocity before and after the vestibular rehabilitation using TPAD. Furthermore, both stride and walking speed significantly increased after the three-months therapy on the condition of not wearing TPAD.
Conclusions: The present findings suggested that the sensory vibratory substitution with TPAD for defective vestibular information induced the brain plasticity related to sensory reweighting to reduce visual dependence of posture control, resulting in the improvement of imbalance without wearing TPAD in the vestibular patients. Therefore, TPAD is a promising vestibular rehabilitation device.
PPII:27 - Effects of vestibular rehabilitation and dual-task training on balance and gait in stroke survivors
Brooke Nairn1, Doris-Eva Bamiou1, Diego Kaski2, Nehzat Koohi1, Marousa Pavlou1
1University College London, The Ear Institute, United Kingdom
2University College London, The Institute of Neurology, United Kingdom
Purpose: Evidence supports that vestibular rehabilitation therapy (VRT) improves the dynamic balance of stroke survivors, yet VRT is rarely included in stroke rehabilitation guidelines. We aim to answer the question: What are the effects of VRT and/or dual-task (DT) training on balance and gait for reducing the risk of falls among sub-acute and chronic stroke survivors?
Methods: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Statement (PRISMA) guidelines, electronic databases PubMed, EMBASE, MEDLINE, Web of Science, and Scopus for English were searched to identify randomised controlled trials (RCT) published within the last 10 years in the English language, investigating VRT for sub-acute and chronic stroke patients.
Results: Eleven studies (n=509 participants) were included in the systematic review, and 10 studies (n=413 participants) were included in a meta-analysis. The average participant age was 60.9, with 62.11% male. On average, 36 months had passed since stroke onset. The pooled effect standardised mean difference (SMD) suggests that VRT has a significantly large effect for improving balance (SMD = 0.71, 95% CI [0.36, 1.05], p <0.00001), particularly from balance-specific training (SMD=1.41, 95% CI [0.23, 2.60], p=0.02). Cognitive-motor DT (CM-DT) training moderately improved gait (SMD=0.46, 95% CI [0.18, 0.74], p=0.001), with greater benefits from DT training compared to single-task training. VRT interventions less than 6 weeks (SMD=0.88, 95% CI [0.19, 1.56], p=0.01), of 3 or more sessions per week (SMD=1.15, 95% CI [0.43, 2.17], p=0.004), which are less than 30 minutes each (SMD=0.9, 95% CI [0.24, 1.57], p=0.008) produced larger effects on balance and gait compared to their equal and opposite counterparts.
Conclusions: Despite substantial heterogeneity across studies, the evidence supports that VRT is safe for improving balance and gait outcomes among sub-acute and chronic stroke patients with an optimal programme including balance specific and CM-DT training, delivered for <6-weeks with >3-sessions per week of <30-minutes per session.
PPII:28 - Effects of vestibular rehabilitation for residual dizziness in patients with benign paroxysmal positional vertigo
Tomohiko Kamo1, Hirofumi Ogihara2, Masato Azami3, Hiroaki Fushiki4
1Department of Physical Therapy, Faculty of Rehabilitation, Gunma Paz University, Japan
2Department of Rehabilitation, Faculty of Health Sciences, Nagano University of Health and Medicine, Japan
3Department of Physical Therapy, Faculty of Health Sciences, Japan University of Health Sciences, Japan
4Otolaryngology, Mejiro University Ear Institute Clinic, Japan
Purpose: The purpose of the present study is to assess the effects of vestibular rehabilitation on dizziness and balance in patients with benign paroxysmal positional vertigo who had residual dizziness after canal repositioning maneuvers.
Methods: This study was designed as a systematic review and meta-analysis. The population consisted of individuals 20 years old or older who were patients with residual dizziness after a canal repositioning procedure. The intervention was vestibular rehabilitation. We included individual RCTs, cluster-RCTs, quasi-RCTs, and crossover trials. Outcomes were dizziness, dizziness handicap inventory (DHI), and gait function. The electronic databases examined included PubMed, Cochrane Central Register of Controlled Trials, EMBASE, and PEDro. We performed the meta-analysis using Cochrane Review Manager software (RevMan 5.4.1).
Results: The database search identified 4205 records, which included 1535 duplicates. After removing duplicates, the titles and abstracts were screened, and 22 of 2670 studies were accepted. Of these studies, 6 were eligible and included in the meta-analysis. Four studies, including 100 patients, reported dizziness. Vestibular rehabilitation did not significantly reduce subjective dizziness compared with the control or placebo group (SMD, −0.59; 95% CI, −1.44 to 0.26). Three studies, including 76 patients, reported DHI. Vestibular rehabilitation did not significantly improve DHI (MD, −2.29; 95% CI, −6.26 to 1.69). Four studies, including 100 patients, reported gait function. Vestibular rehabilitation significantly improved gait function (SMD, 1.45; 95% CI, 0.28 to 2.63).
Conclusions: The present study demonstrated that vestibular rehabilitation improved gait function in patients with benign paroxysmal positional vertigo who had residual dizziness after canal repositioning maneuvers.
PPII:29 - Enhancement of Vestibular Compensation by Retigabine
Kang Yoon Park1, Gyu cheol Han2, Sung huhn Kim3
1Yonsei university,college of medicine, Korea
2Gil hospital, Department of Otorhinolaryngology, Korea
3Yonsei university, Department of Otorhinolaryngology, Korea
Purpose: Acute unilateral vestibulopathy is no treatment method to recover the vestibular function, instead, visual and postural stability accomplished by central vestibular compensation. And there is no definitive therapeutic agent that can stimulate vestibular compensation as well as recovery of vestibular function.
Methods: Unilateral labyrinthectomy was performed in 8-week-old C57BL/6 mouse. Retigaine (10 μg/g) or DMSO was injected i.p. in the mice immediately after the labyrinthectomy. The mean slow phase velocity of spontaneous nystagmus and vestibulo-ocular reflex in slow harmonic acceleration and step velocity test was measured before labyrinthectomy, 1 hour, 12 hour, 48 hour, and 7 days after labyrninthectomy. The same experiment was performed in Kcnq4p.W277S/p.W277Smice to confirm the effect of retigabine in the wild type mice. To investigate the effect of retigabine on vestibular compensation, immunohistochemistry for c-Fos and KCNQ4 in vestibular nucleus was performed.
Results: After the unilateral labyrinthectomy, spontaneous nystagmus was developed to the contralateral side of the labyrnithectomy in all mice. The mean slow phase velocity of spontaneous nystagmus was more significantly reduced in the retigabine injected mice than DMSO injected mice at 48 hours (0.60 vs. 0.24 deg/sec) and 7 days (0.25 vs. 0.09 deg/sec) after the labyrinthectomy. In sinusoidal harmonic acceleration test, gain value was significantly increased in the retigabine injected mice than DMSO injected mice at 7 days in 1.28Hz (0.13 vs. 0.20). In contrast, retigabine showed no effect on labyrinthectomized Kcnq4p.W277S/p.W277Smice. In immunohistochemistry, c-Fos protein expression was increased in the vestibular nucleus of retigabine injected mice when compared to that of DMSO injected mice. But Kcnq4p.W277S/p.W277Smouse doesn’t have any different.
Conclusions: Based on the observation, KCNQ4 stimulator was likely to enhance vestibular compensation after acute vestibular injury. The role of other KCNQ channel in the vestibular compensation should be evaluated in the future because retigabine can stimulate other KCNQ channels.
PPII:30 - Evaluation of the Effectiveness of Vestibular Electrical Stimulation in Vestibular Rehabilitation
Bilal Burak Bayraklı1, Canan Çelik2, Ömer Kuzu1, Özlem Öztürk Tan3
1Ankara Bilkent City Hospital, Department of Physical Medicine and Rehabilitation, Ankara, Türkiye
2University of Health Sciences, Ankara City Hospital, Department of Physical Medicine and Rehabilitation, Ankara, Türkiye
3Ankara Bilkent City Hospital, Department of Neurology, Ankara,Türkiye
Purpose: This study aimed to evaluate the effectiveness of the supervised vestibular rehabilitation (VR) program and vestibular electrical stimulation (VES) applied to trapezius and cervical paravertebral muscles together with rehabilitation program in patients with chronic unilateral vestibular hypofunction (UVH).
Methods: Forty patients aged 18-65, diagnosed with UVH by video head impulse test, were included in the study and were randomized into two groups. 4-week supervised VR program was applied to one group (3 days a week, 12 sessions in total) and VES was applied to the other group in addition to the supervised VR program (3 days a week, 12 sessions in total). Sociodemographic characteristics of the patients were recorded. The groups were evaluated pre-treatment and post-treatment with clinical parameters including Dizziness Disability Inventory (DHI), Visual Analogue Scale (VAS), Berg Balance Scale (BBS), Timed Up and Go Test (TUG), Activity-Specific Balance and Confidence Scale (ABCs), Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI) and Static Posturography.
Results: The study was completed with 38 patients. It was observed that there was no statistically significant difference between the supervised VR (n=19) and supervised VR+VES (n=19) groups in terms of demographic data and clinical parameters before treatment (p>0.05). Statistically significant improvements were detected in DHI, VAS, BBS, ABCs parameters after treatment in both groups (p<0.05). Additionally, statistically significant improvements were noted in VR+VES group in TUG, BAI, BDI, and right Limits Of Stability (LOS) parameters (p<0.05). When the groups were compared, statistically significant differences were observed in BAI and right LOS values in VR+VES group (p<0.05).
Conclusions: The results of the study suggest that supervised VR is beneficial in improving functionality, dizziness severity, balance and activity-related self-confidence in patients with chronic UVH, and that adding VES to supervised VR program contributes to more positive results in terms of reducing anxiety and improving stability and balance maintenance function.
PPII:31 - Evaluation of the efficacy of mobile Internet-based personalized vestibular rehabilitation for otogenic vertigo
Wen Lu1, Yini Li1, Jie Li1, Zhengnong Chen1, Yanmei Feng1, Hui Wang1, Dongzhen Yu1, Haibo Shi1, Shankai Yin1
1Department of Otolaryngology Head and Neck Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, China
Purpose: 基于移动互联网技术和前庭功能障碍状态动态评估, 实时远程调整前庭康复治疗方案。比较个性化和标准化前庭康复治疗的区别, 建立一种方便高效的前庭康复治疗新方法。
Methods: 我们招募了 51 例耳源性眩晕患者, 这些患者于 2019 年 9 月至 2021 年 8 月在 6 个多中心耳鼻咽喉头颈外科住院并自愿入组。基于移动互联网技术, 对前庭功能障碍状态进行动态评估, 实时远程调整患者治疗方案。患者被随机分为标准前庭康复组和个性化前庭康复组。前庭康复 6 个月后进行随访, 以评估两组前庭康复疗效的差异。
Results: 前庭康复6个月后, 个性化前庭康复组DHI评分改善与标准前庭康复组相比有统计学意义 (P=0.0012)。基线DHI评分与患者抑郁、焦虑水平、睡眠质量呈显著正相关 (r=0.6361, P < 0.0001; r =0.5492, P=0.0004; r=0.3971, P=0.0201)。基线时DHI水平与年龄、性别、器官前庭受累或疾病持续时间之间没有显著相关性。其中, 前庭康复前后DHI评分差异有统计学意义 (P=0.0006)。DHI评分改善与前庭康复后抑郁状态呈显著正相关 (r=0.2943, P=0.0157)。
Conclusions: 患者可以受益于基于移动互联网的前庭康复治疗实时远程调整和前庭功能障碍状态的动态评估。个体化前庭康复的疗效优于标准前庭康复计划。
PPII:32 - Factors that influence Adherence to Vestibular Physiotherapy: An exploratory study
Greg Thurlow1, Nick Hill1, Claire Potter1, Hannah Jones1, Lauren Shelvey1, Jeremy Corcoran1
1Guy’s and St. Thomas’ Hospital NHS Foundation Trust, Multidisciplinary Balance Clinic, United Kingdom
Purpose: Adherence to vestibular rehabilitation (VR) has been shown to be associated with improved outcomes. The purpose of this study was to investigate factors that may relate to exercise adherence.
Methods: Between October 2020-2021, a total of 750 patients enrolled in VR. Adherence to 12 weeks of rehabilitation was recorded for 221 patients. Age, age-group (under-, over-65), sex, and modality of initial appointment (face-to-face, video, telephone) were specified for 221 patients, and primary diagnosis for 218 patients. The association of these factors with adherence was analysed by way of t-tests (age) and chi-square distribution testing (nominal data sets).
Results: 174 patients (78.7%) were adherent. There were no significant associations between adherence and age-group (X2(1, N=221) = 2.86, p=0.091)); sex (X2(1, N=221) = 0.12, p=0.729); or primary diagnosis (X2(10, N=218) = 14.33, p=0.159). However, modality of initial appointment showed a significant association with adherence (X2(2, N=221) = 9.94, p=0.007). Face-to-face visits were linked with improved adherence.
There was no age difference between the adherent (M = 53.80, SD = 16.587) and non-adherent groups (M = 51.43, SD = 15.83), unpaired t-test (t(219) = 0.88, p=0.381).
Conclusions: The modality of patients’ initial appointments may impact on their adherence which may subsequently influence VR outcome. Further research is warranted to determine whether other factors may influence patient adherence to VR.
PPII:33 - Patient-reported outcomes are associated with sleep volume in people with unilateral vestibulopathy
Lien Van Laer1, Hanna Koppelaar - van Eijsden2, Ann Hallemans3, Vincent Van Rompaey4, Luc Vereeck3
1Department of Rehabilitation Sciences and Physiotherapy / Movant, Faculty of Medicine and Health Science, University of Antwerp, Antwerp, Belgium ; Multidisciplinary Motor Centre Antwerp (M2OCEAN), University of Antwerp, Antwerp, Belgium ; Department of Otorhinolaryngology and Head & Neck Surgery, Antwerp University Hospital, Antwerp, Belgium
2Gelre Hospitals, Apeldoorn Dizziness Centre, The Netherlands. Leiden University Medical Center, Department of Otorhinolaryngology, The Netherlands
3Department of Rehabilitation Sciences and Physiotherapy / Movant, Faculty of Medicine and Health Science, University of Antwerp, Antwerp, Belgium
4Department of Otorhinolaryngology and Head & Neck Surgery, Antwerp University Hospital, Antwerp, Belgium; Department of Translational Neurosciences University of Antwerp, Antwerp, Belgium
Purpose: Literature revealed that individuals with vestibular disorders present with poorer sleep quality compared to healthy adults. In addition, associations between sleep quality and patient-reported outcomes were described in individuals with vestibular disorders. Therefore, this cross-sectional study aims to examine the correlation between sleep volume and patient-reported outcomes in acute unilateral vestibulopathy (AUVP).
Methods: Individuals with AUVP were recruited from June, 2021 until January, 2024. Participants meeting the Barany Society criteria for AUVP wore a tri-axial accelerometer (MOX-logger, Maastricht University) for 7 days at 10 weeks post-onset to assess their sleep volume. Additionally, participants completed the Dizziness Handicap Inventory (DHI) and Vestibular Activities Avoidance Instrument (VAAI). Regression analyses investigated associations between sleep volume (dependent variable) and age, sex, vestibular function (vestibulo-ocular reflex-gain), and patient-reported outcomes.
Results: Eighty consecutive participants with MOX-data were included (mean age 55.1 ± 16.6 years; 40 men and women) with an ipsilesional VOR gain of 0.70 ± 0.25 at 10 weeks post onset. The mean sleep volume was 443.3 ± 61.3 minutes/night. The regression analyses revealed that an increased sleep volume was significantly associated with a higher perceived handicap as measured by the DHI (r2= 0.048, β= 0.702, p= 0.050) and presence of fear avoidance beliefs as measured by the VAAI (r2= 0.125, β= 1.632, p= 0.001). Demographics and vestibular function showed no significant relationship with sleep volume.
Conclusions: The results of this study confirm that a higher sleep volume is associated with increased perceived disability and fear-avoidance beliefs, adding to the existing literature and confirming a link between sleep and the presence of symptoms in individuals with AUVP.
PPII:34 - Refining the TeleRehabilitation Decision Support System for stroke patients: a patient-centric approach
Brooke Nairn1, Doris-Eva Bamiou1, Nehzat Koohi1
1University College London, The Ear Institute, United Kingdom
Purpose: Stroke, the leading cause of adult disability in the developed world, results in long-term balance problems for 85% of survivors. Current rehabilitation programmes lack comprehensiveness and individualisation, leading to high dropout rates and poor outcomes. This project leverages AI-supported remote technology for multisensory vestibular rehabilitation in older adult’s post-stroke. Recognizing the absence of a gold-standard protocol and the digital exclusion commonly faced by older adults with disabilities, feedback from clinicians and stroke survivors will help to refine the TeleRehabilitation Decision Support System (TeleRehab DSS) for stroke-tailored multisensory vestibular rehabilitation.
Methods: Two focus groups were conducted at University College London between February-July 2023, including physiotherapists, neurologists, and stroke survivors aged 50–80. Following a presentation of the TeleRehab DSS, qualitative data was collected through semi-structured interviews and open-ended discussion. Adopting a reflexive thematic analysis approach, open and axial coding was completed using Nvivo 12 to achieve both code and meaning saturation of themes. Responses were recorded, transcribed verbatim, and analysed responsibly as per the Guidance for Reporting Involvement of Patients and the Public (GRIPP) and Standards for Reporting Qualitative Research (SRQR).
Results: Common themes emerged across both focus groups, indicating appreciation for TeleRehab DSS's engagement and useful features but concern over the setup burden, particularly with the insoles. Suggestions for improvement focused on addressing stroke-specific issues, including spasticity, upper-limb function, and aphasia, with simpler exercise instructions and additional exercises proposed.
Conclusions: Following clinician and stroke survivors feedback, refinement of the TeleRehab DSS is essential for addressing stroke-specific needs, including a more comprehensive baseline assessment of limitations. Solutions for increased patient engagement require clear exercise instructions with a simpler setup and consideration of alternative solutions to the insoles. These findings will help to refine the TeleRehab DSS into a more patient-centric platform for implementation within the proof-of-concept study.
PPII:35 - Relationship between Exercise Adherence and Vestibular Rehabilitation Outcome
Nick Hill1, Claire Potter1, Hannah Jones1, Gregory Thurlow1, Lauren Shelvey1, Jeremy Corcoran1
1Guy's Hospital, Vestibular Physiotherapy, Multidisciplinary Balance Clinic, London UK
Purpose: The effect of exercise adherence on vestibular rehabilitation (VR) outcome remains uncertain. This study explored whether adherence affected scores on two patient-reported outcome measures (PROMS).
Methods: Adults referred for VR, between October 2020-September 2021, with symptoms of dizziness and/or unsteadiness of any aetiology, were assessed. The Dizziness Handicap Inventory (DHI) completed at pre- (week 0) and post- (week 12) VR, and a single-item global rating of change (GROC) scale, measured effectiveness. The GROC scores were dichotomised into ‘+/- signs of improvement’. A single-item rating of adherence (ROA) scale measured adherence. Adherence served as a between-subjects factor, and effects on the GROC and DHI were assessed by Chi-Square test of independence and two-way ANOVA, respectively.
Results: 750 patients (mean(+/-SD) age 55(17) years; 71% female) enrolled in VR. ROA scores were recorded for 221 patients; 174 (78.7%) were adherent. 83% of the adherent group showed subjective signs of improvement, compared to 40% of the non-adherent group. There was a significant relationship between ROA and GROC outcomes, X
2
(1, N=221) =34.3, p<.001. Adherence was associated with subjective improvement. DHI scores were recorded for 128 patients, of which 118 had adherence specified. There was a mean reduction only in the adherent group (n=99) of 15(+/-24) points, with a significant interaction effect between treatment stage and adherence demonstrated; F(1, 116)=6.41, p=.033.
Conclusions: Adherence to VR interventions is associated with treatment outcome according to two different measures of clinical effectiveness. Further research is required to investigate factors that influence patient adherence to VR and underlying causality.
PPII:36 - Retropulsion – a frequent postural disorder in neurorehabilitation
Jeannine Bergmann1, Lisa-Marie Huber1, Carmen Krewer2, Friedemann Müller1, Klaus Jahn3
1Schoen Clinic Bad Aibling, Research Group, Bad Aibling, Germany
2Schoen Clinic Bad Aibling, Research Group and Technical University Munich, Bad Aibling, Germany
3Schoen Clinic Bad Aibling and German Center for Vertigo and Balance Disorders, LMU Munich, Bad Aibling, Germany
Purpose: Retropulsion is characterized by a posterior shift of the center of mass with a tendency to fall backwards, problems in actively shifting the center of mass forward and resistance to passive correction. Similar to lateropulsion, patients with retropulsion seem to orient their body towards an impaired inner reference of verticality. Retropulsion seems to occur in different neurological disorders such as stroke, Parkinson, normal pressure hydrocephalus, and geriatric conditions. With the Scale for Retropulsion (SRP) we recently developed a valid and reliable assessment to diagnose and quantify retropulsion. Although retropulsion appears to be important for neurorehabilitation, research is very limited. The present study aimed to investigate the prevalence of retropulsion in an inpatient rehabilitation setting.
Methods: Physiotherapists assessed the SRP prospectively in patients admitted to neurorehabilitation at the Schoen Clinic Bad Aibling. The scale includes four subtests: A) static postural control, B) reactive postural control, C) resistance, and D) dynamic postural control which are tested in a sitting and standing (initial) position. The score ranges from 0 (no signs of retropulsion) to 24 (very severe retropulsion). The SRP is a bedside test which can be easily implemented into the clinical routine (application time is 5–10 minutes).
Results: Patients were assessed between 05/2021 and 02/2022. Data revealed that retropulsion is frequent: Over all 65,6% (122 of 186) of the patients showed signs of retropulsion (SRP score ≥1). The median SRP score in these patients was 12 (Q1,Q3 5,19) and covered the whole range of the scale. The prevalence of retropulsion in different neurological disorders was 69% (63/91) in stroke, 56% (10/18) in critical illness myopathy/polyneuropathy, 53% (9/17) in traumatic brain injury, 93% (13/14) in Parkinson’s Disease, and about 30-40% in multiple sclerosis and spinal cord syndrome.
Conclusions: Retropulsion is a frequent postural disorder in neurorehabilitation that occurs in various neurological diseases.
PPII:37 - Sensory substitution therapy using a new wearable device for patients with bilateral vestibulopathy
Go Sato1, Sho Takaoka1, Kazunori Matsuda1, Miki Tomura1, Yoshirou Wada2, Tadashi Kitahara2, Noriaki Takeda1, Yoshiaki Kitamura1
1Tokushima University Graduate School of Biomedical Sciences, Department of Otorhinolaryngology-Head and Neck surgery, JAPAN
2Nara Medical University, Department of Otolaryngology-Head and Neck Surgery, JAPAN
Purpose: We assessed the effects of sensory substitution therapy using a new wearable device in patients with bilateral vestibulopathy.
Methods: We have developed a wearable device, Tilt Perception Adjustment Device (TPAD) that transmits vibratory input containing head-tilt information to the mandible in substitution of defective vestibular information in patients with bilateral vestibulopathy. The tilt angle of the head in the roll plane is sensed by the tilt sensor, and the vibration strength of the vibrator is increased in accordance with the head tilt angle. Five patients with bilateral vestibulopathy were enrolled in this study. All patients were trained to maintain a centered body position by ensuring the vibrator signals and completed 20 minutes training sessions two times per day for 3 months. We assessed the dizziness handicaps inventory (DHI), the CoP of posturography, and performed gait analysis using the motion capture system in this study.
Results: The DHI score was significantly improved after the three-month therapy using TPAD. The stride and walking speed were improved on the condition of wearing TPAD. However, the CoP and the gait parameters did not change after the three-month therapy on the condition of not wearing TPAD.
Conclusions: These findings suggested that the sensory vibratory substitution with TPAD caused a temporary replacement for defective vestibular information in patients with bilateral vestibulopathy. Therefore, TPAD is applicable as a wearable device for improving unsteady gait to prevent a fall in patients with bilateral vestibulopathy.
PPII:39 - The effectiveness of a treatment combining vestibular rehabilitation and cognitive therapy in persistent dizziness
Lene Kristiansen1, Birgit Juul-Kristensen2, Stein Helge Glad Nordahl3, Birgitte Espehaug4, Kjersti Thulin Wilhelmsen4, Liv Heide Magnussen4
1Norwegian National Advisory Network on Vestibular Disorders, Dept of Otorhinolaryngol & Head Neck Surgery, Haukeland University Hospital, Bergen, Norway/ Department of Health and Functioning, Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, Bergen, Norway
2Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
3Norwegian National Advisory Network on Vestibular Disorders, Dept of Otorhinolaryngol & Head Neck Surgery, Haukeland University Hospital, Bergen, Norway
4Department of Health and Functioning, Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, Bergen, Norway
Purpose: To investigate the effectiveness of a group treatment integrating vestibular rehabilitation and cognitive behaviour therapy (VR-CBT) on participants with persistent dizziness in a community setting.
Methods: A randomised controlled trial was conducted with participants allocated to VR-CBT (n=53) or control (n=52). The VR-CBT intervention was conducted as group-treatment with eight participants completing eight treatment-sessions. The control group received two phone calls during a 6-month period. The participants were tested at baseline and after 6 and 12 months. Main outcomes were the Dizziness Handicap Inventory (DHI) and preferred gait velocity. Secondary outcomes included body flexibility (four elements from the Global Physiotherapy Examination (GPE), dizziness intensity before and after head movements (numeric rating scale (NRS still/moving)), the Vertigo Symptom Scale short-form (VSS-SF), the Body Sensation Questionnaire (BSQ) and the Hospital Anxiety and Depression questionnaire (HADS). Group differences in change from baseline were estimated with linear mixed-effects models.
Results: Preliminary results: Reductions in DHI was larger with VR-CBT than control after 6 (-6.8 points, 95% CI: -11.8 to -1.9, p= 0.01) and 12 months (-6.5 points, 95% CI: -12.5 to -0.4, p= 0.04). Results for change in preferred gait velocity were in favour of VR-CBT, but not statistically significant (p-values ≤ 0.15). At 6 months, the BSQ and NRS measures showed results in favour of VR-CBT (p= ≤ 0.002), which also applied for NRS moving at 12 months (p= 0.02).
Conclusions: The VR-CBT treatment was more effective in reducing DHI compared to telephone follow-up. For other outcomes, results were less consistent, particularly over time.
PPII:40 - The Symptoms & Mechanisms of Recovery in Scuba Divers with Inner Ear Decompression Sickness
Rosie Stokes1, Jonathan Marsden2
1School of Health Professions, University of Plymouth & Diving Diseases Research Centre, Plymouth, UK
2School of Health Professions, University of Plymouth, UK
Purpose: Inner ear decompression sickness is manged with hyperbaric recompression therapy whilst vestibular rehabilitation exercises are not utilised as standard. The pattern and extent of recovery over time has not been described and will aid in an understanding of symptom burden and allow a more informed assessment when considering fitness to return to diving.
Methods: Eleven divers presenting to the DDRC Healthcare hyperbaric chamber in Plymouth UK (07/21-01/24) undertook a range of vestibular tests at initial presentation, on discharge and at 3-month follow up. These included: Videonystagmography, Posturography, Dynamic Gait Index, Rod-and-Disk test, and Patient Reported Outcome Measures. A personalised vestibular rehabilitation programme was also initiated.
Results: Results from the 7 divers who presented acutely and had follow up testing, all showed an improvement in nystagmus, dynamic gait index, and patient reported outcome measures over time. Initial VNG testing showed decreased VOR gain in the dark and reduced time constant with step rotation. Six of the 7 divers showed a persistent deficit on follow up testing, with divers describing return of some symptoms with fatigue, alcohol, viral illness, and low light environments.
Conclusions: Clinical improvement was seen in all divers despite an ongoing peripheral deficit in vestibular function in 6 of the 7 divers, indicating a central compensatory mechanism. The burden of residual symptoms when this central compensatory mechanism is compromised seems substantial in some divers and has the potential to impact safety on future diving.
PPII:41 - The User Acceptance Test for the TeleRehab Prototype among Patients with Mild Cognitive Impairment
Thipok Bovornratanaraks1, Gulnaz Magauina2, Noppawan Tundiew3, Nattawan Utoomprurkporn4, Chavit Tunvirachaisakul5, Doris Bamiou6
1Faculty of Medicine, Chulalongkorn University, Thailand
2Graduate Affairs, Faculty of Medicine, Chulalongkorn University, Thailand
3Chula Unisearch, Chulalongkorn University, Thailand
4Hearing Speech and Balance Center/Neuroscience Center, King Chulalongkorn Memorial Hospital, and Otolaryngology Department, Faculty of Medicine, Chulalongkorn University, Thailand
5Old Age Psychiatry Department, Faculty of Medicine, Chulalongkorn University, Thailand
6UCL Ear Institute, Faculty of Brain Science, University College London, United Kingdom
Purpose: With the global prevalence of Mild Cognitive Impairment (MCI) on the rise, the risk of fall among the older population due to a combination of impaired cognitive and motor functions is becoming a major public health concern. Thailand has seen an alarming prevalence of MCI, especially in rural areas. Falls among MCI patients can be particularly dangerous. Therefore, a multifaceted fall prevention measure shall be widely implemented. As such, we aim to evaluate the user’s acceptability of the TeleRehab System Prototype, which offers remote personalized balance training via holographic instructions and exergames.
Methods: Seven MCI patients were invited to try using the TeleRehab prototype, which composed of augmented reality goggles displaying cognitive and balance training games, wearable sensors, and a mobile application. Participants were then asked to complete the System Usability Scale (SUS) and the User Experience Questionnaire (UEQ)
Results: The median (interquartile range) SUS score of 70 (62.5 to 75) indicated moderate to favorable opinions (scores above 68 out of 100 are considered above average) regarding the system’s overall usability. According to the UEQ, all sub-scales were rated positively (5 points or more from a 1 to 7 scale), with Attractiveness receiving the highest rating. However, the range is particularly wide in terms of Stimulation. Interestingly, some participants, despite rating the UEQ positively, expressed their concerns regarding the system’s heavy weight, visual issues, and difficulty equiping the system.
Conclusions: This study demonstrates the positive acceptance of the TeleRehab system among Thai MCI patients. Despite a favorable SUS and UEQ result, improvements in some areas can be made to further enhance user acceptability. While the concept and software were well-received, the physical design of the system received some complaints, particularly the weight. These findings can lead to the optimization of the TeleRehab system, hence leading to a more user-friendly remote balance training program.
PPII:42 - Vestibular Infant Screening – Rehabilitation: protocol in paediatric vestibular rehabilitation
Marieke Fontaine1, Ingeborg Dhooge2, Cleo Dhondt1, Ruth Van Hecke3, Frederic Acke2, Lena Van den Bossche1, Helen Van Hoecke2, Els De Leenheer2, Leen Maes4
1Department of Head and Skin, Ghent University Faculty of Medicine and Health Sciences, Ghent, Belgium
2Department of Head and Skin, Ghent University Faculty of Medicine and Health Sciences & Department of Otorhinolaryngology, Head and Neck Surgery, Ghent University Hospital, Ghent, Belgium
3Department of Rehabilitation Sciences, Ghent University Faculty of Medicine and Health Sciences, Ghent, Belgium
4Department of Rehabilitation Sciences, Ghent University Faculty of Medicine and Health Sciences & Department of Otorhinolaryngology, Head and Neck Surgery, Ghent University Hospital, Ghent, Belgium
Purpose: A peripheral vestibular dysfunction can have a substantial impact on children’s overall development. Therefore, it is of utmost importance that vestibular-induced problems are treated early and effectively through Vestibular Rehabilitation Therapy (VRT). Although VRT is sufficiently proven and standardised in adults, a lack of evidence about treatment efficacy in children remains. To assess the effectiveness of paediatric VRT, the Vestibular Infant Screening – Rehabilitation (VIS-REHAB) protocol was developed (1) to investigate the short-term effect of a combined postural control and gaze stabilisation protocol, compared to no therapy, and (2) to investigate the most important factors (personal, disease-related, socioeconomic) that may influence the effect of the VIS-REHAB protocol in a group of vestibular-impaired children. This study aims to establish evidence-based rehabilitation guidelines, facilitating access to the most effective and suitable therapy. This is expected to limit the impact on various developmental domains.
Methods: The VIS-REHAB study is a two-parallel group, superiority, randomised controlled crossover trial with 1:1 allocation ratio. The study includes patients aged 3-17 years old with identified peripheral vestibular dysfunction. Primary and secondary outcome measures assess gaze stability, postural control, motor development and quality of life. Statistical analyses will involve parallel group and crossover analysis, along with prespecified subgroup analyses using ANCOVA and linear mixed models.
Results: Results are pending given the nature of the article (protocol article).
Conclusions: The VIS-REHAB protocol presents the first high-quality, large-scale study on the effectiveness of VRT encompassing both gaze stability and postural control exercises in vestibular-impaired children of a broad age range.
PPII:43 - Vestibular Migraines, BPPV, PPPD: Clinical Conundrum for Physical Therapists- A Case Report
Puneet Dhaliwal
1
1State University of New York, Downstate Health Sciences University
Purpose: Patient (Pt) 35/ F presented to Physical Therapy with balance and severe vertigo. Pt with h/o Migraine headaches, BPPV / Recurrent BPPV. Key symptoms: Dizziness; Vertigo (Rotatory and pulling sensation); Headaches; Balance Deficits; Difficulty in walking outdoors and standing activities; Unable: recreational activities and work.
Medical Hx: Crohn’s Disease, Intermittent diplopia (years), Anxiety (seeks Therapeutic care) h/o major vertigo (2012, 2015, 2016, 2017; May2022);Headaches: 2-3 times a week/ dizziness everyday.
Medications: Emgality -improved headache, not dizziness; Clonazepam0.25 mg; Venalafaxine 37.5 mg started 2ndweek of Jan’23; D3 1000 IU; Mg 100 mg; B2 100 mg ; Riztriptan 5 mg – no help with dizziness.
Methods: Romberg’s Eyes open (EO) (Firm Surface – FS): 30 secs, LOB.
Romberg’ Eyes Closed (EC) (FS) : 10 secs, severe sway and LOB
Motion Sensitivity on VAS:
Bending activities : 8-9/10 Fast head turns: 5-6/10; 8-9/10 with cervical extension
180 degree turns – severe instability and dizziness : 8-9/10
ABC Score: 20% Reports feeling of the tilt to the Left (L)side; with head tilt to Right ∼ 10 degrees; DGI : 10/24
Normal Cranial Nerve examination
Rotatory Chair: Normal
Calorics: confounding per ENT, but Nrml, Pt did not repeat VNG
Position Test: L DHP: Downbeating Nyst L torsion, latency 5 secs, lasted > 2 minutes May present with upbeating L torsional nystagmus lasting < 20 secs. SN: L beating nystagmus at times without fixation.
Results: ABC score 80% by end of 1 year
Dizziness with daily activities reduced 3/10 in all mentioned tasks
Patient ability to walk 20 – 30 blocks
Complete resolution of BPPV with CRM
DGI score: 18/24; Minimal tilt (< 2deg on non migraine day)
Conclusions: A complex vestibular patient needed Medical management ( Venlafexine) and Vestibular Rehabilitation including Sensory reweighing to manage symptoms of vertigo during Migraine and BPPV attacks. Ability to receive PT reduced anxiety and fear and helped return to social activities and work.
PPII:44 - Virtual reality controlled by a novel locomotion device to modulate vestibular perception
Wilhelmina Tan1, John Straub1, Slobodan Paessler2, Tomoko Makishima3
1University of Texas Medical Branch, John Sealy School of Medicine, USA
2University of Texas Medical Branch, Departmet of Pathology, USA
3University of Texas Medical Branch, Department of Otolaryngology, USA
Purpose: Vestibular dysfunction influencing balance and posture, is a major risk factor for falls. Falls frequently result in injuries requiring medical treatment and restrict of everyday activities such as standing or walking. Vestibular physical therapy (PT) is effective to improve vestibular function and subsequently preventing fall-related morbidities. Many with vestibular dysfunction have limited physical mobility, in addition to the perception of dizziness, which limit their access to traditional PT. Therefore, identifying new effective vestibular PT methods is crucial. Virtual reality (VR), a computer-generated simulation of real or imaginary environments that allows user interactions, has been applied to vestibular PT and has demonstrated effectiveness. Our goal was to trial VR with a novel locomotion device and test if an assisted standing position of the body allowing for a different way of controlling movement could effectively stimulate the vestibular system.
Methods: Healthy subjects were recruited for this pilot study. Vestibular tests, history and physical examination, and a questionnaire was performed before and after the VR session. The VR stimulus was delivered as a visually and proprioceptively interactive realistic “underground garage” environment through the commercially available Meta Quest 2 VR headset (Meta) and the C-Infinity locomotion device (NeuroSync Laboratories). The subjects explored the underground garage VR content for 3 minutes. The test results before and after VR were compared.
Results: Preliminary results on the computerized dynamic posturography showed “visually” improved balance function without change in “somatosensory” function. The largest modulation was seen in the vestibular scores, both positive and negative. The questionnaire showed subjective improvement in oculomotor perception, albeit with feelings of disorientation.
Conclusions: We conclude that our VR setup is effective for the modulation of vestibular perception in healthy subjects both subjectively and objectively. We will further investigate how to effectively apply vestibular stimulation in different body positions.
24. Vestibular Migraine
PPII:45 - Clinical features and vestibular evaluation of vestibular migraine with and without Peripheral Vestibular Dysfunction
Qianqian Wang1, Xinyan Ma1, Jianrong Wang1, Yuan Xu1, Xia Ling2, Yuru Wang1, Siru Xue1, Xu Yang1
1Peking University Aerospace School of Clinical Medicine (Aerospace Center Hospital), Department of Neurology, China
2Peking University First Hospital, Department of Neurology, China
Purpose: To investigate the differences of the clinical features and vestibular ocular motor function evaluation in patients diagnosed as vestibular migraine with peripheral vestibular dysfunction (P-VM) and vestibular migraine without peripheral vestibular dysfunction (C-VM).
Methods: Based on the diagnostic criteria of the Bárány Society and the International Headache Society, 159 patients with VM were included, divided into P-VM and C-VM, and also enrolled 31 migraine participants (control group) for a comparative study. We collected clinical data from the three groups of patients mentioned above and further improved the evaluation of vestibular ocular motor function.
Results: Patients with C-VM exhibit internal vertigo (78.0%, 92/118), while patients with P-VM frequently show external vertigo (65.9%, 27/41) and positional vertigo (43.9%, 18/41) (P˂0.001). The prevalence of motion sickness history in the C-VM group (72.0%, 85/118) is significantly higher than the P-VM group (43.9%, 18/41) and the MC group (32.3%, 10/31) (P˂0.001). The positive rate of smooth pursuit in the C-VM group (28.8%, 34/118) was significantly higher than the P-VM group (14.6%, 6/41) and the MC groups (9.7%, 3/31) (P=0.03). And only the P-VM group exhibited abnormalities in SVH and SVV, the C-VM group and the MC group both being normal.
Conclusions: There are significant differences between the two groups of patients in clinical core symptoms, vestibular ocular motion and vestibular otolith pathways, further indicating that P-VM may represent an independent clinical subtype.
PPII:46 - Day-to-day symptom burden in patients with vestibular migraine: Long-term effects of comorbid conditions
Jeffrey Staab1, Scott Eggers2, Deanna Hofschulte3, Neil Shepard4, Devin McCaslin5
1Mayo Clinic in Minnesota, Departments of Psychiatry and Psychology and Otorhinolaryngology - Head and Neck Surgery, USA
2Mayo Clinic in Minnesota, Department of Neurology, USA
3Mayo Clinic in Minnesota, Department of Psychiatry and Psychology, USA
4Mayo Clinic in Minnesota, Department of Otorhinolaryngology - Head and Neck Surgery, USA
5University of Michigan, Ann Arbor, Department of Otolaryngology, USA
Purpose: To identify causes of long-term morbidity in patients with vestibular migraine (VM).
Methods: Participants with VM enrolled in a randomized clinical trial of rizatriptan versus placebo kept weekly logs of days that they experienced headache, unsteadiness/dizziness, sensitivity to self-motion, and sensitivity to environmental motion as a secondary aim to investigate long-term morbidity. Individuals with probable VM, other uncompensated vestibular disorders, or contraindications to rizatriptan were excluded. Participants with more than four VM attacks/month received migraine prophylaxis and those with non-excluded illnesses including persistent postural-perceptual dizziness (PPPD) and psychiatric disorders received usual care to stabilize those conditions before undertaking study treatment. Data were examined at 4-week intervals using repeated measures multivariate analyses of variance controlled for participants’ demographics, and presence/absence of PPPD, psychiatric disorders, use of migraine prophylaxis, and use of psychiatric medications.
Results: Participants were enrolled until they treated three VM attacks with study drug. Weekly symptom logs were available from 66 participants at week 4, 45 at week 16, 15 at week 48, and lesser numbers (too few to analyze) up to week 216. Short-term results (weeks 0-16): Based on least squares means of symptomatic days/week, participants with VM+PPPD reported significantly greater morbidity, 22-67% more days with headache, 43-135% more with unsteadiness/dizziness, 55-244% more with self-motion sensitivity, and 91-555% more with environmental motion sensitivity than those without PPPD (e.g., week 16, unsteadiness/dizziness, 2.85 vs. 1.48 days, p<0.008). Long-term results (weeks 20-48): Participants with VM+PPPD had 46-95% more days with headache than those without PPPD. After week 24, participants with VM reported minimal unsteadiness/dizziness or sensitivity to self or environmental motion compared to participants with VM+PPPD (e.g., week 48, unsteadiness/dizziness, 2.43 vs. -0.11days, p<0.002). No other covariates added significant morbidity. Study medication did not affect results.
Conclusions: Among participants with VM, co-existing PPPD added significant short-term morbidity and caused most long-term symptom burden.
PPII:47 - DIAGNOSTIC CHALLENGE: MIGRAINE WITH AURA, VESTIBULAR MIGRAINE OR MIGRAINE INDUCE BY VESTIBULAR ACTIVATION
Rosalyn Chaves Araujo1, María José Fernández Nava1, Sandra Martín García1, Alejandro Jesús Tamayo Esquinas1, Elena De Rodrigo Tobías1, Gonzalo Martín Hernández1
1Hospital Nuestra Señora de Sonsoles
Purpose: Migraine with aura, vestibular migraine and migraine induced by vestibular activation are independent but pathophysiologically related entities, whose diagnosis may be delayed when triggering factors, such as menstruation, are present.
Methods: 33-year-old woman, migraine sufferer, seen in otoneurology consultation for dizziness and vertigo crisis of variable duration, instability, photophobia, sonophobia, nausea and moderate bitemporal and pulsatile headache of 16 months of evolution. The episodes began in the postpartum period and appeared at the same time as menstruation.
Results: The otoscopy, vestibular clinical examination and v-HIT were normal. Cerebral and cervical MRI without pathological findings. Cranial base MRI showed an anatomical variant of the right anteroinferior cerebellar artery entering inside the right ICA (type III of CHAVDA).
The gynecological examination and hormonal study were normal. VNG without alterations, except for hyperreactivity with significant accompanying vegetative cortex clinics. With the results obtained and in consensus with the neurology department, the patient was diagnosed with vestibular migraine.
Conclusions: In daily practice, the distinction between migraine and vestibular migraine is a challenge. A complete anamnesis and a neurological and vestibular examination are essential, as well as the exclusion of other possible causes. Although the result of the caloric test is indifferent in the diagnosis of vestibular migraine, its realization can guide us, since sometimes in migraineurs it can trigger a crisis or provoke an important vegetative cortex clinic.
The multidisciplinary approach is essential to achieve an early diagnosis that improves the quality of life of these patients.
PPII:48 - Dispelling Mist That Obscures Positional Vertigo in Vestibular Migraine
Sulin Zhang1, E Tian1, Jun Wang1, Zhaoqi Guo1, Jingyu Chen1
1Department of Otorhinolaryngology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan City, Hubei Province, P. R. China
Purpose: Patients with vestibular migraine (VM) often present with positional vertigo. A portion of these patients have features of benign paroxysmal positional vertigo (BPPV). It is a challenge to rapidly identify the BPPV component of VM associated with positional vertigo.
Methods: Retrospective data collected from 60 VM and 47 VM + BPPV patients were used to build a diagnostic model, and then prospective data from 47 patients were used for the external validation. All patients had VM manifesting as positional vertigo, with or without accompanying BPPV. The clinical manifestations and the results of vestibular function tests were comprehensively analyzed using logistic regression.
Results: The univariate and multivariate analyses showed that the age, symptom duration, tinnitus, ear fullness, nausea, head shaking nystagmus, the direction of the Dix–Hallpike and roll tests, and horizontal gain could help differentiate between the two groups. A nomogram and an online calculator were generated. The C-index was 0.870. The diagnostic model showed good discriminative power and calibration performance during internal and external validation.
Conclusions: This study provided a new perspective for diagnosing VM with positional vertigo by identifying the BPPV component and, for the first time, offers a prediction model integrating multiple predictors.
PPII:49 - Early detection and monitoring of hearing loss in vestibular migraine: Extended high-frequency hearing
Sulin Zhang1, Zhaoqi Guo1, Jun Wang1, E Tian1, Jingyu Chen1
1Department of Otorhinolaryngology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan City, Hubei Province, P. R. China
Purpose: Vestibular migraine (VM) presents mainly with recurrent vestibular symptoms and migraine. A great number of patients with VM have cochlea symptoms such as tinnitus, hearing loss.
Methods: A cross-sectional study was conducted on patients with definite VM (dVM) and probable VM (pVM) who met the diagnostic criteria. Auditory-vestibular tests and psychological assessments were performed. Logistic regression was used to evaluate the predictive effect of EHF pure tone audiometry (PTA) for standard frequency (SF) hearing loss.
Results: Fifteen patients with pVM and 22 patients with dVM were recruited. Overall, the two most vertigo types were vestibulo-visual symptoms (83.78%) and internal vertigo (54.05%). A vertigo attack persisted for <5 min in approximately 57% of patients, compared with 5 min to 72 h in 43%, and lasted longer than 72 h in 8%. Approximately 87% of patients had psychological disorders. Most patients with VM (92%) suffered from some degree of EHF hearing impairment, and 68% had SF hearing loss, which is substantially higher than their complaints (43%). Moreover, the mean EHF hearing threshold cutoff value (57 dB HL) worked well in predicting SF hearing loss (area under curve, AUC, 0.827), outperforming distortion product optoacoustic emission (AUC, 0.748).
Conclusions: VM has a wide range of clinical manifestations. Hearing loss had a considerably higher rate compared to actual complaints. Moreover, patients with VM tended to have bilateral EHF and high-frequency hearing loss. The effectiveness of the mean EHF hearing threshold cutoff value in predicting hearing loss supported its use in the early detection of hearing loss and monitoring disease progression.
PPII:51 - Effectiveness of Anti-CGRP Medication in Asian Vestibular Migraine: Obesrvational Study
Toru Miwa1, Teppei Kouga2
1Kyoto University, Department of Otolaryngology- Head and Neck Surgery, Kyoto, Japan
2Osaka Metropolitan University, Department of Otolaryngology, Osaka, Japan
Purpose: Migraine and dizziness often coexist, with vestibular migraine (VM) presenting with vestibular symptoms and headaches. Calcitonin gene-related peptide (CGRP) may be involved in motion-induced symptoms; however, the results of studies on anti-CGRP monoclonal antibodies (mAbs) for the treatment of VM have been equivocal. This study aimed to clarify the efficacy of anti-CGRP mAbs in VM treatment.
Methods: This observational cohort study assessed 12 patients with VM who were treated with anti-CGRP mAbs (CGRP group) or served as 11 controls for 6 months. Clinical questionnaires and equilibrium tests were administered, with primary outcomes including changes in the Dizziness Handicap Inventory (DHI) score. Statistical analyses, including analysis of variance, were used to assess the treatment effects of anti-CGRP mAbs.
Results: The CGRP group showed significant improvements in DHI scores and number of vertigo/dizziness attacks per month after 6 months. No significant difference was observed in the control group.
Conclusions: Early treatment with anti-CGRP mAbs was more effective than conventional treatment in preventing migraine in patients with VM. While our findings offer valuable insights into personalised treatment approaches by identifying factors associated with treatment responsiveness, the study’s retrospective design and limited sample size warrant further prospective studies.
PPII:53 - Human RAMP1 overexpressing mice are resistant to migraine therapies for motion sensitivity
Shafaqat Rahman1, Anne Luebke1
1University of Rochester Medical Center, Rochester, NY 14642 USA
Purpose: Increased motion sensitivity correlates with the severity of vestibular migraine symptoms. Systemic CGRP has previously been shown to exacerbate motion-induced nausea in wild-type C57B6/J mice and postural sway in female mice. Olcegepant, a CGRP receptor antagonist, can reverse both effects. In this study, nestin/hRAMP1, a mouse model with elevated human RAMP1 expression that enhances CGRP signaling in the nervous system, was used to investigate motion-induced nausea and static imbalance.
Methods: As behavioral surrogates, we performed motion-induced thermoregulation and postural sway center of pressure (CoP) experiments in male and female nestin/hRAMP1 mice and compared them to unaffected littermates. Mice were evaluated in these assays following intraperitoneal (IP) injections of i) vehicle control, ii) CGRP (0.1 mg/kg), or iii) CGRP (0.1 mg/kg) co-administered with either olcegepant (1.0 mg/kg CGRP receptor antagonist) or rizatriptan (1.0 mg/kg selective serotonin receptor agonist).
Results: We show that overexpression of hRAMP1 in the nervous system causes increased postural sway in both female and male mice at baseline and that systemic CGRP has no additive effect. We also show that in these RAMP1-overexpressing mice, olcegepant no longer rescues the increased postural sway and motion-induced nausea.
Conclusions: This study suggests that hypersensitivity to CGRP may model the clinical symptoms of vestibular migraine. This work was supported by R01 DC017261 (AEL).
PPII:54 - Motion sickness whilst reading as a passenger in the car is highly predictive of vestibular migraine
Diego Kaski1, Lucia Joffily2, Konstantina Rova3, Lara Carvalho4, Nehzat Koohi1
1University College London
2Universidade Federal do Estado do Rio de Janeiro
3G. Papanikolaou General Hospital, Greece
4University College London Hospitals NHS Foundation Trust, United Kingdom
Purpose: Vestibular Migraine (VM) is a prevalent vestibular disorder, affecting up to 2.7% of the general population. The clinical diagnosis of VM remains challenging due to its complex pathophysiology and symptom overlap with other dizziness disorders. Motion sickness is a core feature of migraine and can be interrogated through simple questionnaires. This study aims to identify to what extent motion sensitivity can predict VM compared to other causes of dizziness.
Methods: We conducted a cross-sectional study involving 113 patients from the vestibular neurology clinics at University College London Hospitals. Participants were categorised into VM, Persistent Postural Perceptual Dizziness (PPPD), combined VM and PPPD, and 'other' dizziness aetiologies. Data on motion sickness history and dizziness during car travel were collected through structured interviews and analysed using logistic regression to assess the predictive value of these symptoms for VM.
Results: A substantial portion of patients with VM (91.2%) reported nausea or dizziness when reading as a passenger, a symptom significantly more prevalent than in those with PPPD or other dizziness diagnoses. Logistic regression indicated that VM patients are significantly more likely to experience these symptoms compared to non-VM patients, with an odds ratio suggesting a strong predictive value for this symptom in diagnosing VM.
Conclusions: The findings highlight increased motion sensitivity while reading in a moving vehicle as a promising diagnostic tool for VM, offering a practical aid in clinical settings to distinguish VM from other vestibular disorders.
PPII:55 - Optokinetic stimulation effect on VEPMs in Vestibular Migraine
Patricia Castro1, Meltem Ozen2, Laura Freeman3, Elvira Cortese2, Anca-Diana Grigore2, Nehzat Koohi2, Diego Kaski2
11. Adult Diagnostic Audiology department, University College London Hospitals trust, UK. 2. Universidad del Desarrollo, Escuela de Fonoaudiologia, Facultad de Medicina Clinica Alemana, Chile
2SENSE research unit, Department of clinical and movement neuroscience, Institute of Neurology, University College London, UK
3Withington Community Hospital, Manchester University NHS Foundation Trust, Manchester, UK
Purpose: Vestibular migraine (VM) is the commonest cause of non-positional episodic vertigo worldwide. However, the lack of understanding of the underlying pathologic mechanisms of VM translates into delayed diagnosis and insufficient methods to monitor disease progression. It has been previously proposed that abnormal cortical interaction in patients with VM may cause hyper- excitability of the visual cortex to suppress vestibulo-cortical areas. These findings however required a laboratory setup that cannot be achieved in a clinical setting. There remains a need therefore for a bedside vestibular measure that can be of diagnostic utility for VM.
Methods: Accordingly, we used cervical vestibular evoked myogenic potentials (cVEMP) - before and after a full-field OKN stimulus - to explore changes in vestibular responses in patients with VM and healthy controls. Thirty VM patients and their age and sex matched controls participated. Participants had 500Hz tone burst cVEMPs completed before and after exposure to a rightward moving OKN stimulus for 3 minutes.
Results: Interim analysis shows that VM patients did not show an elevated baseline cVEMP compared to control, or a significant change in amplitude post OKN stimulus exposure. Nevertheless, changes in wave morphology and intensity were observed.
Conclusions: Thirty VM patients and their age and sex matched controls participated. Participants had 500Hz tone burst cVEMPs completed before and after exposure to a rightward moving OKN stimulus for 3 minutes.
PPII:56 - Spontaneous and positional nystagmus in vestibular migraine crisis: A two cases report
Diego Olmedo1, Cristofer Salazar1, Ângela Reis-Rego2, Paula Altamirano3
1Hospital Clinico Universidad de Chile, Otorhinolaryngology, Chile
2Hospital Santa Maria, Otorhinolaryngology, Portugal
3Clinica INDISA, Otorhinolaryngology, Chile
Purpose: Describe the characteristics of positional nystagmus in two cases of vestibular migraine (VM) investigated during the ictal period, arguing the pathophysiology of positional nystagmus in each case.
Methods: Two subjects were observed in may and june 2023 in the Otorhinolaryngology Service of the Hospital Clínico Universidad de Chile. The subjects were evaluated with videonystagmography, according to the following protocol: (1) evaluation of spontaneous nystagmus; (2) positional nystagmus evaluation; (3) caloric test; and (4) audiometry.
Results: Case 1 presents with spontaneous upbeat nystagmus (SPV: 7°/s), which is suppressed with fixation and does not follow Alexander’s law. In the positional nystagmus evaluation, only spontaneous nystagmus is observed. Audiometry and caloric tests are normal. In Case 2, we have negative spontaneous nystagmus. In the positional nystagmus evaluation, persistent positional upbeat nystagmus non-paroxysmal, indefatigable, without associated sensation of vertigo is observed. Normal audiometry. The caloric test expressing bilateral vestibular hypofunction. Also, a VHIT is performed, presenting vestibular hypofunction (in terms of VOR gain) in all stimulation planes, in both ears. None of the subjects have alterations in ocular motility.
Conclusions: The vasospasm generated in the VM crisis could possibly generate variations in the density ratio of the endolymph with respect to the cupula, like heavy cupula type, expressing what was observed in the results.
PPII:57 - Systemic PACAP and CGRP have comparable effects on nausea and postural sway measures in preclinical models
Shafaqat Rahman1, Abigal Dweh1, Anne Luebke1
1University of Rochester Medical Center, Rochester, NY 14642 USA
Purpose: Migraine and vestibular migraine (VM) are disorders associated with increased motion sensitivity leading to symptoms of motion-induced nausea and static imbalance. Antagonism of CGRP signaling is an established therapy, but not all patients respond. In this study, we compared systemic PACAP with systemic CGRP to investigate motion-induced nausea and static imbalance in mice.
Methods: As behavioral surrogates, we performed motion-induced nausea and center of pressure (CoP) postural sway experiments in male and female C57B/6 mice. Mice were evaluated in these assays following intraperitoneal (IP) injections of i) vehicle control, ii) CGRP (0.1 mg/kg) (Sigma-Aldrich), or iii) 0.3 mg/kg PACAP-38 (Bachem). These studies were performed in 80 wildtype C57BL/6J (JAX 664) mice (40F/40M). For the motion-induced nausea test, head and tail temperatures were measured with a FLIR E60 IR camera before, during, and after 20 min of orbital rotation (0.75 Hz to 4 cm displacement). For postural sway testing, mice were placed on a force platform and forces and moments were recorded before and after a brief vestibular challenge.
Results: We confirmed that in both female and male mice during provocative motion, there is a decrease in head temperature which recovers, and an associated short-lasting tail skin vasodilation . Interestingly, both systemic CGRP and systemic PACAP-38 injections caused similar reductions in head temperature, but there was no associated tail skin vasodilation, suggesting severe motion-induced nausea. In addition, mice showed increased postural sway after either systemic CGRP or PACAP-38 injection.
Conclusions: Our finding that systemic CGRP and PACAP have comparable effects on motion-induced nausea and measures of postural sway in mice suggests that PACAP-targeted drugs may be effective in patients who do not respond to CGRP-based therapeutics. This work was supported by R01 DC017261(AEL).
PPII:58 - The prognosis of vestibular migraine depends on the results of vestibular exmaninations
Fumiyuki Goto1, Koichiro Wasano1, Shouji Kaneda1, Kenji Okami1
1Tokai University, school of medicine, department of otolaryngology
Purpose: Several studies have reported reduced or absent vestibular evoked myogenic potential (VEMP) responses in patients with VM indicating a dysfunction of the vestibulo-collic reflex. Despite the increasing number of studies related to VM, most of these reports have focused on the characteristics of the disease, including the results of neurotologic tests, and its treatment and prognosis related to the vestibular abnormalities have not yet been fully documented. It is important to understand the prognostic factors to predict the disease course with treatment and to properly counsel VM sufferers and conduct appropriate therapeutic planning. In our current study, we evaluated the response to medications in VM patients and determined the association between treatment responsiveness and abnormal vestibular results.
Methods: The subjects were 25 patients with VM. The battery of vestibular examinations as well as several questionaries were conducted at the initial evaluation. The conventional pharmacological prophylactic treatment and lifestyle modification of VM were performed. After 4 weeks of the treatment, clinical improvements were evaluated by clinical global improvement scale (CGI-s). The relation between the score of CGI-S and the result of several vestibular examinations were evaluated.
Results: As a results, neither V-HIT nor posturography predicted the prognosis. There are 5 normal, 6 unilateral, and 14 bilateral no response in 500hz o-VEMP. CGI-s of normal, unilateral and bilateral no response was 1.4±0.5, 2.8±1.3, and 3.1±1.2, respectively. There is statistically significant difference between normal and bilateral no response (P<0.05). The presence of the response of bilateral o-VEMP or AR of c VEMP<40 was the indicator of good treatment outcome.
Conclusions: The vestibular examinations especially o or c VEMP would be beneficial for the prediction of the treatment outcome of VM.
PPII:59 - Utility of videonystagmography in the differentiation of mechanical BPPV from Migrainous positional vertigo
PRATISHTHA SACHAN
1
1RSM HOSPITAL, ENT DEPARTMENT, LUCKNOW
Purpose: To Assess the utility of videonystagmography (VNG) in distinguishing between mechanical BPPV caused by otolithic debris and Migrainous positional vertigo (MPV)
Methods: A study was conducted on 50 patients of BPPV, 50 patients of MPV, aged 12 to 80 years to establish patterns of nystagmus(physiology), assessing parameters like slow phase velocity (First beat, Peaking of the peak beat, Last discernible beat ) of nystagmus, time, amplitude, latency, reversibility, & fatiguability in various VNG tests.
Results: A statistically significant difference (p value<0.05) was found between MPV and BPPV in Vertical smooth pursuit & Dix Hallpike test. While other test showing nonsignificant abnormalities. In MPV Prevalence of vertical nystagmus (up and downbeat with/without torsional component) is high in comparison to horizontal nystagmus (left and right-beating , apogeotropic horizontal nystagmus) , less common pure torsional variants . However, in MPV, the nystagmus exhibited low frequency, low amplitude, and low/high slow phase velocity (status migrainous) . Conversely, the crescendo-descendo pattern is typical of BPPV (mechanical fall), where particles fall under gravitational force. Initially, there is a gain in velocity, followed by deceleration due to resistance offered by endolymphatic fluid, and then a subsequent gain in velocity due to gravitational pull (storage velocity). Furthermore, the assessment of otolith mass size can be done by VNG.
Conclusions: By analysis of nystagmus with VNG ,we can easily discriminate between the most common positional variant (BPPV) from the 2ndmost common positional variant MPV to reach the diagnosis.
PPII:60 - Videonystagmography findings in Vestibular Migraine
Prateek Porwal1, Pradeep Vundavalli2
1Vertigo Specialist, PRIME ENT Center, Hardoi, Uttar Pradesh, INDIA
2Asian Super Speciality ENT Hospital, Visakhapatnam, Andhra Pradesh, India
Purpose: Vestibular migraine (VM), also known as migraine-associated vertigo, is a variant of migraine that significantly involves the vestibular system, which is responsible for maintaining balance, spatial orientation, and coordinating eye movements. Vestibular migraine is a clinical diagnosis, and there are no tests or findings that can point towards the diagnosis. In this multicentric study, we have documented a few common VNG (videonystagmography) patterns that are seen in VM patients.
Methods: In this multicentric study, we have documented a few common VNG (videonystagmography) patterns that are seen in VM patients.
Results: The most common findings in our study are impaired smooth pursuit in horizontal and vertical direction, broken saccades, nystagmic intrusions, and hypometric saccades. Spontaneous vertical nystagmus, which is exaggerated on removal of fixation.
Gaze evoked nystagmus, along with rebound nystagmus, central positional nystagmus, is also commonly seen in patients with vestibular migraine. In most patients, there is visual dependency, and the subjective visual vertical is influenced by the background.
Conclusions: While VM is typically diagnosed clinically, it often presents with vestibular and oculomotor abnormalities. Among these, the most commonly observed oculomotor findings include abnormal saccades, smooth pursuit, vertical nystagmus, gaze evoked nystagmus and central positional nystagmus. These VNG findings can be used as a tool to make better diagnosis and help in treatment in patients who have overlapping symptoms with other disorders.
25. Vestibular Neuritis
PPII:61 - 4 hour-delayed 3D-FLAIR MRIs in patients with acute unilateral peripheral vestibulopathy
Sun-Uk Lee1, Yukang Kim1, Donghoon Woo1
1Korea University Medical Center
Purpose: Conventionally, MRI aids in differentiating acute unilateral peripheral vestibulopathy/vestibular neuritis (AUPV/VN) from mimickers. Meanwhile, the diagnostic utility of MRIs dedicated to the inner ear remains to be elucidated for diagnosing AUPV/VN.
Methods: We prospectively recruited 53 patients with AUPV/VN (mean age+-SD = 60+-15 years, 29 men). Initial MRIs were performed with a standard protocol, and an additional axial 3D-fluid attenuated inversion recovery (3D-FLAIR) sequence was obtained 4 h after intravenous injection of gadoterate meglumine. Abnormal enhancement was defined as a signal intensity that exceeded the mean + 2SD value on the healthy side. The findings of neurotologic evaluation and MRIs were compared.
Results: Overall, the inter-rater agreement for gadolinium enhancement was 0.886 (Cohen's kappa coefficient). Enhancement was observed in 26 patients (49%), most frequently in the vestibule (n=20), followed by the anterior (n=12), horizontal (HC, n=8), posterior canal (n=5), and superior (n=3) and inferior (n=1) vestibular nerves. In multivariate logistic regression analysis, the enhancement was associated with decreased HC gain in video head-impulse tests (p=0.036), increased interaural difference in ocular vestibular-evoked myogenic potentials (p=0.001), and a longer onset-to-MRI time span (p=0.024). The sensitivity and specificity were 92.3% and 81.5%, respectively, with an area under the curve of 0.90 for predicting gadolinium enhancement.
Conclusions: Robust gadolinium enhancement was observed on 4 h-delayed 3D-FLAIR images in nearly half of the patients with AUVP/VN, with a good correlation with the results of neurotologic evaluation. MRIs may aid in delineating the involved structures in AUPV/VN.
PPII:62 - Abnormal ASL and other extraocular muscle findings on MRI in a case of presumed acute unilateral vestibular hypofunction
Kristin K. Israel1, Nancy Fischbein2, Eubee Koo3, Tess Veuthey4, Nancy Pham2, Heather Moss3, Kristen K. Steenerson5
1Department of Inpatient Rehabilitation, Stanford Healthcare, Palo Alto, California United States
2Department of Radiology, Stanford Medicine, Palo Alto, California, United States
3Department of Ophthalmology, Stanford Medicine, Palo Alto, California, United States
4Department of Neurology and Neurological Sciences, Stanford Medicine, Palo Alto, California, United States
5Department of Otolarynology –Head and Neck Surgery, Department of Neurology and Neurological Sciences, Stanford Medicine, Palo Alto, California, United States
Purpose: Introduction: Acute unilateral vestibular hypofunction (AUVH), most commonly attributed to vestibular neuritis (VN), typically presents as sudden-onset continuous vestibular symptoms and examination consistent with peripheral-pattern HINTS Plus. We present a case of AUVH with peripheral-pattern HINTS Plus where MRI was indicated and revealed unique, paired extraocular muscle (EOM) muscle findings potentially challenging the diagnosis of AUVH.
Methods: Case:
A 30-year-old male presented to the ED with 1.5 weeks of rocking sensation acutely worsening to continuous room-spinning vertigo with nausea, vomiting, headache, and photosensitivity. The neurological examination noted peripheral pattern HINTS Plus with third-degree, unidirectional, left beating nystagmus, and mild postural instability. A brain MRI, which was ordered due to a prior history of resected frontal cavernous malformation, demonstrated right lateral rectus and left medial rectus enlargement, enhancement, and elevated ASL perfusion. Ophthalmology evaluation confirmed a normal eye examination including no proptosis, no enophthalmos, normal tonometry, and full range of motion of all EOMs. Laboratory evaluation showed an improving mild leukocytosis, otherwise, inflammatory markers, thyroid function, autoimmune screen, and infectious screen to date have been normal. The paraneoplastic work-up is pending at the time of writing.
Results: See case
Conclusions: Discussion:
This seemingly classic case of AUVH yielded an interesting MRI finding of enlargement, enhancement and hyperperfusion of the “slow phase” muscles. These findings pose an interesting concept akin to superior oblique myokymia: primary EOM pathology triggering nystagmus mimicking AUVH vs AUVH nystagmus so robust and long-lasting, it caused imaging-apparent change in EOMs. We favor the latter and suggest that EOM hyperperfusion may emerge as a novel sign in AUVH as ASL is more widely adopted. Completion of his pending inflammatory/paraneoplastic work-up will be critical to understanding the nuanced pathophysiology of this patient’s condition.
PPII:63 - Assessments of subjective visual gravity and spontaneous nystagmus in patients with vestibular neuritis
YAZHI XING1, Zhuangzhuang Li1, Lingkang Dong1, Dongzhen Yu1, Haibo Shi1, Shankai Yin1
1Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Department of Otolaryngology Head and Neck Surgery, China
Purpose: Vestibular neurtitis (VN) is an acute vestibular syndrome with well-established semicircular canal dysfunction. However, the otolith impairments requires further investigation. This study aimed to assess the correlation between the spontaneous nystagmus and the subjective visual vertical/horizontal (SVV/SVH) among VN patients at the different head positions.
Methods: We performed a case-control study recruiting twenty VN patients and thirty healthy subjects. We evaluated the SVV/SVH and the intensity of spontaneous nystagmus in five different head positions: upright, 45° tilt to the left, 90° tilt to the left, 45° tilt to the right, and 90° tilt to the right. Pearson/Spearman correlation analysis was used depending on normal or skewed distribution data.
Results: In VN patients, a significant correlation was observed between spontaneous nystagmus and SVV/SVH in an upright position (r= 0.77, p<0.01). The intensity of spontaneous nystagmus was higher when the head was tilted 90° towards the affected side compared to sitting upright and tilting towards the healthy side (p <0.05). The SVV/SVH displayed an ipsiversive shift, known as the A-effect, when the head was tilted towards both the lesion and unaffected sides, exhibiting a contraversive direction. Furthermore, the changes in position-induced spontaneous nystagmus were consistent with the displacements of SVV (r=0.97, p <0.01) and SVH (r=0.90, p <0.05) caused by head tilt.
Conclusions: The presence of spontaneous nystagmus in VN patients was observed to vary across different head position. These variations could potentially be attributed to the diverse activation patterns of the mechanical properties of otolith organs that are induced by head tilts.
PPII:65 - Correlation of static and dynamic utricular function with vestibular symptoms after acute vestibular neuritis
Seo-Young Choi1, Kwang-Dong Choi1
1Pusan National University Hospital, Department of Neurology, South Korea
Purpose: This study aimed to explore the correlation of static and dynamic otolithic function with vestibular symptoms and the quality of life after acute vestibular neuritis (VN).
Methods: We prospectively recruited 26 patients diagnosed with acute VN and followed them up at one-week and one-month intervals after the initial visit. We assessed static utricular function by measuring subjective visual vertical (SVV) tilt and dynamic utricular function using ocular vestibular-evoked myogenic potentials (oVEMP). Symptom severity and quality of life were evaluated using the Dizziness Handicap Inventory (DHI), Visual Analog Scale (VAS), and the five-level EuroQoL five-dimension (EQ-5D-5L).
Results: Initial assessments showed all patients with abnormal SVV and 92% with abnormal oVEMP. After one week, SVV tilt and oVEMP asymmetry improved significantly. SVV changes correlated significantly with DHI and EQ-5D-5L score improvements (p = 0.046, and p = 0.026, respectively). At one month, SVV tilt improved further, with a notable correlation between SVV changes and EQ-5D-5L score changes (p = 0.005).
Conclusions: Static otolithic function is correlated with vestibular symptoms during the early stage of VN, while dynamic function does not show such a correlation.
PPII:66 - Inflammatory versus iatrogenic etiology of acute unilateral vestibulopathy: clinical impacts
Lien Van Laer1, Ann Hallemans2, Vincent Van Rompaey3, Luc Vereeck4
1Department of Rehabilitation Sciences and Physiotherapy / Movant, Faculty of Medicine and Health Science, University of Antwerp, Antwerp, Belgium; Multidisciplinary Motor Centre Antwerp (M2OCEAN), University of Antwerp, Antwerp, Belgium; Department of Otorhinolaryngology and Head & Neck Surgery, Antwerp University Hospital, Antwerp, Belgium
2Department of Rehabilitation Sciences and Physiotherapy \ Movant, Faculty of Medicine and Health Science, University of Antwerp, Antwerp, Belgium; Multidisciplinary Motor Centre Antwerp (M2OCEAN), University of Antwerp, Antwerp, Belgium
3Department of Otorhinolaryngology and Head & Neck Surgery, Antwerp University Hospital, Antwerp, Belgium; Department of Translational Neurosciences, Faculty of Medicine and Health Sciences, University
4Department of Otorhinolaryngology and Head & Neck Surgery, Antwerp University Hosptial, Antwerp, Belgium; Department of Translational Neurosciences, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
Purpose: Acute unilateral vestibulopathy (AUVP) can arise from diverse causes, encompassing inflammatory etiologies like vestibular neuritis, and iatrogenic etiologies such as vestibular schwannoma resection. This cross-sectional study aimed to compare clinical outcomes between inflammatory (IF) and iatrogenic (IA) AUVP etiologies.
Methods: Participants meeting the Barany Society Criteria for AUVP were enrolled in the study. At ten weeks post-onset, assessments included measures of vestibular function (e.g., vestibulo-ocular reflex (VOR) gain), objectively measured physical activity data using MOX-loggers (Maastricht University), and patient-reported outcomes such as the Dizziness Handicap Inventory (DHI), Vestibular Activities Avoidance Instrument (VAAI), and the Hospital Anxiety and Depression Scale-Anxiety/Depression (HADS-A/D). These measures were then compared between individuals with IF or IA etiologies of AUVP.
Results: The study comprised 66 cases of IF and 37 cases of IA etiologies. IA etiologies exhibited poorer vestibular function, decreased physical activity levels, and worse results on patient-reported outcome measures compared to IF etiologies at ten weeks post-onset. Significant differences included VOR gain (IA: 0.63±0.25 vs. IF: 0.74±0.24, p=0.041), total physical activity time in minutes/week (IA: 394.5±243.8 vs. IF: 767.0±371.2, p<0.001), sedentary time in minutes/week (IA: 5642.3±902.6 vs. IF: 4830.6±920.8, p=0.003), DHI (IA: 28.4±20.1 vs. IF: 19.3±19.2, p=0.025), VAAI (IA: 22.6±14.2 vs. IF: 12.2±12.4, p<0.001), and HADS-D (IA: 4.5±3.8 vs. IF: 2.7±3.0, p=0.012).
Conclusions: IA etiologies of AUVP lead to significantly worse clinical outcomes at ten weeks post-onset compared to IF etiologies. This discrepancy may stem from irreversible and complete loss of vestibular function or possible complications arising from the medical procedure itself.
PPII:67 - Lindsay and Hemenway syndrome - from theory to practice
Haider Alsarhan
1
1college of medicine / Mustansiriyah University - Baghdad IRAQ
Purpose: For a better understanding of the presence of unilateral vestibular hypofunction represented by evidence of one side vestibule-ocular reflex deficit with concomitant ipsilateral benign positional vertigo involving the posterior semi-circular canal.
Methods: A review of literature and a case presentation including Results of video-oculo-graphy recordings along with the results of other vestibular testing will be shown, list of differential diagnosis including typical vestibular neuritis, typical posterior canal benign positional paroxysmal vertigo, multi-canal benign positional paroxysmal vertigo, and cerebellar dysfunction will be listed along with methods of confirmation of the diagnosis.
Results: There is a wide controversy in the literature regarding Lindsay Hemenway syndrome in the name of the syndrome, etiology, presentations, course of the disease, and treatment. Special considerations in the treatment of this syndrome are recommended.
Conclusions: There are wise variations in the presentations of Lindsay Hemenway syndrome; vestibular specialists should keep this syndrome in his /her mind when examining cases of vertigo; otherwise it will be easily missed with result of incomplete treatment of the condition.
PPII:68 - Optimizing vestibular neuritis management with modular strategies
Sulin Zhang1,Fei Li2, Dan Liu1, Jun Wang1
1Department of Otorhinolaryngology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan City, Hubei Province, P. R. China
2Department of Neurology, Second Affiliated Hospital of Naval Medical University, Shanghai, China.
Purpose: This study proposes a “modular management” approach for vestibular neuritis (VN) to reduce chronicization and improve patient prognosis. The approach involves multi-factor grading and hierarchical intervention and was found to be more effective than traditional treatment strategies.
Methods: This retrospective analysis compared two groups of VN patients from two medical institutions. The intervention group of 52 patients received “modular management,” while the control group of 51 patients did not receive this kind of management. Analyzed the early treatment strategies, 6-month prognosis, and other indicators of the two groups of patients, compared and analyzed their overall prognosis, and identified the risk factors affecting the chronicization.
Results: The modular management group had lower dizziness severity, better balance, lower anxiety, and higher video head impulse testing (v-HIT) gain after 6 months of onset. Analysis of factors related to persistent postural-perceptual dizziness (PPPD) in patients with VN showed positive correlations between the time from onset to diagnosis and PPPD, and Vertigo Symptom Scale (VSS), Dizziness Handicap Inventory (DHI), anxiety, and depression. Normalized vestibular rehabilitation was negatively correlated with PPPD, while gender, age, and early steroid use had no significant correlation. The multi-factor logistic regression model correctly classified 93.20% of the study subjects with a sensitivity of 87.50% and specificity of 94.90%.
Conclusions: The proposed “modular management” scheme for VN is a comprehensive and dynamic approach that includes health education, assessment, rehabilitation, therapy, evaluation, and prevention. It can significantly improve patient prognosis and reduce chronicization by shifting from simple acute treatment to continuous management.
PPII:69 - Recurrent side-alternating acute unilateral vestibulopathy – description of two cases
Maritta Spiegelberg1, Alexander Andrea Tarnutzer2
1Cantonal Hospital of Baden
2Cantonal Hospital of Baden and University of Zurich, Zurich, Switzerland
Purpose: Acute unilateral vestibulopathy (AUVP) is usually a monophasic disease. Rarely, patients suffer from AUVP more than once. With very limited knowledge about this condition, we aimed to provide a detailed description of the clinical presentation of recurrent AUVP.
Methods: Retrospective review of all cases with quantified sequential AUVP observed at our institution (2018-2024).
Results: Two patients were identified. They developed a contralesional AUVP 10 months and 34 months, respectively, after the first AUVP. In both cases no hearing deficits or other focal neurologic deficits could be detected. On video-head-impulse testing (vHIT) during the first AUVP, a superior-branch impairment of the vestibular nerve was observed in both cases (reduced angular vestibulo-ocular reflex (aVOR) gain and catch up-saccades of the horizontal and superior canal). Vestibular testing (vHIT, cVEMPS, oVEMPS) after six weeks demonstrated complete recovery in one patient. The other patient was not available for testing at that time. The second (contralesional) episode of AUVP occurred after 10 months and 34 months, respectively. One patient showed impairment of all three canals, the saccule and utricule. The other patient demonstrated again a diminished aVOR-gain of the horizontal and superior semicircular canal only. MR-Imaging (performed during the first episode in one patient and after the second episode in the other patient) was normal. Recovery after the second episode was incomplete in both patients at follow-up.
Conclusions: Unlike sudden hearing loss or idiopathic facial palsy, relapse in AUVP – being rare in frequency - seems to occur preferentially contralesional and with worse outcome for the second episode.
PPII:70 - The long-term outcome of vestibular function in the patients with vestibular neuritis
Sohichiroh Moriya1, Kazuhiko Kubo2, Taishi Kii3
1Kyushu Central Hospital, Department of Otorhinolaryngology
2Chidoribashi General Hospital, Department of Otorhinolaryngology & Head and Neck Surgery, JAPAN
3National Hospital Organization Kyushu Medical Center, Department of Otorhinolaryngology & Head and Neck Surgery, JAPAN
Purpose: Vestibular neuritis (VN) is a very common cause of acute vestibular disorder and is characterized by the sudden caloric areflexia. The cause of VN still remains unclear and the effect of corticosteroid on VN are controversial. However, prolonged dizziness decreases the quality of life. The aim of this study is to verify the long-term period of recovery of vestibular function in the patients with VN.
Methods: The subjects with VN were recruited at Chidoribashi General Hospital. All of them were evaluated by both caloric test and cervical vestibular evoked myogenic potentials (cVEMP). When the patients had severe or complete loss of caloric response without any other reason, they were diagnosed as VN. The various parameters such as age, sex, caloric response and cVEMP were collected from electric medical records retrospectively. The current study was approved by our ethical committee.
Results: Many patients had recovery from caloric areflexia within a year, especially in the group of patients with the treatment using corticosteroid. The same result was obtained regarding cVEMP.
Conclusions: The current study suggests that the treatment using corticosteroid may recover the vestibular function more effectively.
26. Vestibular Prosthesis
PPII:73 - A Novel Surgical Approach and Microelectrode Array for Selective Stimulation of Otolith End Organs in Chinchillas
Celia Fernandez Brillet1, Charles C Della Santina2
1Johns Hopkins University, Department of Biomedical Engineering, USA
2Johns Hopkins University, Departments of Otolaryngology–Head & Neck Surgery and Biomedical Engineering, USA
Purpose: We previously characterized the normal otolith-ocular reflex (OOR) in chinchillas and showed the possibility of eliciting OOR responses using electrical stimulation. The electrodes we used for that research were inserted toward the maculae through ampullotomies on the horizontal and superior semicircular canals, precluding a direct view of the utricle and saccule. This less-invasive approach was chosen to increase the likelihood of hearing preservation. The array's planarity, stiffness and small dimensions made insertion into the intended locations challenging and low yield.
Methods: We prioritized directly viewing the medial wall of the vestibule for precise and reliable identification of the utricle and saccule through a more invasive approach. We developed a new, custom-designed 52-channel microelectrode array (MEA) based on skull prosections and a microMRI model of a chinchilla labyrinth and nerve anatomy. We designed the array to unfold and conform to the medial wall of the vestibule, fitting the anatomy and promoting consistent and successful MEA placement.
Results: Using the new surgical approach, an implanted animal recovered successfully for at least nine months post-op. OOR responses were compared to a standard response from our published datasets. The new approach, which decreased the distance between the electrode contacts and the target neuroepithelia, yielded smaller response thresholds and elicited larger eye velocities. The same stimulation paradigm (1 Hz sinusoidal pulse frequency modulation) with half the current amplitude (100 µA) yielded eye movements ≤100 deg/s, five times larger than with the previous surgical approach.
Conclusions: Using a more invasive approach allows us to get a direct view of the medial wall of the vestibule, where the utricle and saccule reside. Due to the visibility of the otoconia, this approach increases the probability of successfully implanting the new MEA, enabling more selective and reliable stimulation of different branches of the utricular and saccular nerves.
PPII:74 - Assessing interactions with a vestibulo-cochlear implant: auditory performance in static and dynamic settings
Benjamin Volpe1, Elke Devocht1, Bernd Vermorken1, Stan van Boxel1, Joke Debruyne1, Angelica Perez-Fornos2, Nils Guinand2, Raymond van de Berg1
1Division of Balance Disorders, Department of Otorhinolaryngology and Head and Neck Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
2Service of Otorhinolaryngology and Head and Neck Surgery, Department of Clinical Neurosciences, Geneva University Hospitals, Geneva, Switzerland
Purpose: The vestibulo-coclear implant (VCI) aims to restore both hearing and vestibular function: nine electrodes are placed in the cochlea (CI) and one in each of the three semicircular canals (VI). Combined stimulation of VCI electrodes may induce interactions that could affect both components’ performance. Adjustments to the CI stimulation pattern accommodate vestibular pulses and simultaneous stimulation may spread current between auditory and vestibular organs. The study aims to investigate whether the combined functionality of a VCI affects auditory performance and explore potential interactions.
Methods: Nine patients with bilateral vestibulopathy and sensorineural hearing loss received a unilateral implant and underwent CI rehabilitation. Speech comprehension scores using the clinical CI processor were compared to a clinical cohort of CI recipients (10-12 CI electrodes). Subsequently, replacement of the CI processor by the experimental VCI processor was evaluated. Finally, the effect of introducing VI co-stimulation was tested: word recognition in quiet and digit-in-noise tests were performed in static settings as well as two dynamic settings (platform moving at 10 and 15 degrees/second) while using the VCI in three different modes (baseline stimulation, modulating from 50% baseline, modulating from reduced baseline).
Results: Speech comprehension learning curves of VCI patients showed a similar trend and comparable outcome to those of a reference population. Comparisons between the CI and the VCI processor, with and without baseline VI stimulation, yielded consistent scores. No significant differences were found in speech scores in quiet or in noise between static and dynamic conditions in either VI stimulation mode.
Conclusions: This study highlights the promising potential of the VCI in co-restoring auditory and vestibular function. Consistent speech perception scores across various combined stimulation modes suggest the feasibility of VCI integration on auditory performance. Further research is needed to refine VCI functionality and comprehend its long-term impact on both auditory as well as vestibular performance reciprocally.
PPII:75 - Balance improvement after cochleo-vestibular implantation - which is responsible?
Joyce Tang1, Ángel RAMOS DE MIGUEL2, Isaura RODRIGUEZ MONTESDEOCA3, Juan Carlos FALCÓN GONZÁLEZ3, Silvia BORKOSKI BARREIRO3, Andrzej ZAROWSKI4, Morgana SLUYDTS4, Nadia FALCÓN BENITEZ2, Ángel Ramos Macias3
1Singapore General Hospital, Department of Otolaryngology Head and Neck Surgery, Singapore
2University of Las Palmas De Gran Canaria, Hearing and Balance Laboratory, Spain
3Complejo Hospitalario Universitario Insular Materno Infantil De Gran Canaria, Department of Otolaryngology and Head and Neck Surgery, Spain
4European Institute For Otorhinolaryngology, Gza Hospitals Antwerp, Belgium
Purpose: Many cochlear implant candidates have concurrent vestibulopathy. Some authors have demonstrated improvement in balance after cochlear implantation and have thus hypothesized that there might be beneficial “cross-talk” from the cochlear implant to the vestibular end-organs.
Bionic\VEST is being developed by the European Consortium as a treatment for bilateral vestibulopathy as defined by the Bárány Society. The device is a custom-modified cochlear implant CI24RE (VEST), from Cochlear Ltd. with a full-banded straight electrode array with 3 contacts for otolith end-organ stimulation (E1-3), and a perimodiolar electrode array with 19 half-banded contacts for cochlear stimulation (E4-22).
Using this case-control study is to analyze the differing effects of electrical cochlear stimulation (CI) vs vestibular (otolith end-organ) stimulation (VI), we are able to demonstrate whether the improvement in balance results from cochlear stimulation or vestibular stimulation.
Methods: Four patients with bilateral vestibulopathy were included. Dynamic Gait Index (DGI), computed dynamic posturography (CDP), vestibular-ocular reflex (VOR) gain measured using video head impulse test (vHIT), acoustic cervical myogenic responses (cVEMP) recordings, and electrical cVEMP were tested in all cases. Transimpedance Matrix (TIM) analysis was used to evaluate the current flow from the cochlea to the vestibule.
Results: When only the CI was activated, there was no improvement in the DGI. However, when the VI was activated (without the CI), the DGI of all 4 patients improved by an average of 38%. Additionally, the CDP also demonstrated improvement with use of the VI.
Our findings suggest that any current flow from the cochlear space to the otolith organs was insufficient for effective cross-stimulation. The functional results correlated with the data obtained in Transimpedance Matrix analysis, confirming that there is no current flow from the cochlea to the vestibule.
Conclusions: The vestibular stimulation from the cochleo-vestibular implant is solely responsible for the improved balance in subjects.
PPII:76 - Cognitive assessment in human patients equipped with a vestibulo-cochlear implant
Anissa Boutabla1, Divya A. Chari2, Gautier Grouvel1, Julie Corre1, Jean-François Cugnot1, Samuel Cavuscens1, Maurizio Ranieri1, Lukasz Bola3, Raymond Van de Berg4, Richard F. Lewis2, Nils Guinand1, Angélica Pérez Fornos1
1Division of Otorhinolaryngology Head and Neck Surgery, University of Geneva and Geneva University Hospitals, Geneva, Switzerland
2Department of Otolaryngology – Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA
3Institute of Psychology, Polish Academy of Sciences, Warsaw, Poland
4Division of Balance Disorders, Department of Otorhinolaryngology and Head and Neck Surgery, Maastricht University Medical Center, Maastricht, the Netherlands
Purpose: Vestibular information improves navigation in rodents, but studies in human subjects with vestibular damage have been less conclusive. Herein, we studied the effects of prosthetic vestibulo-cochlear implant (VCI) short-term stimulation on navigation and neuropsychologic function in patients with bilateral vestibulopathy.
Methods: Two patients with severe bilateral vestibulopathy who underwent VCI surgery in 2021 completed neuropsychological tests and a virtual reality based spatial navigation task. Neuropsychological testing included the Corsi Block Test (CBT), Digit Span Test (DST), and an egocentric mental transformation task (EMT). In the navigation task, the subject performed a “return-to-home” task based on the “triangle completion test” in two conditions: (1) dynamic, in which the subject turns in yaw and steps in place, and (2) static, in which the head and body are stationary, and the subject navigates with buttons on a controller. Testing was performed at least 1 month prior to VCI stimulation, during stimulation, and at least 1-month post-stimulation.
Results: Both subjects demonstrated improved performance on the DST and EMT during VCI stimulation, and subject 1 showed improvement on the CBT during stimulation. On the navigation task, both subjects demonstrated improved accuracy (measured by angular error) and precision (measured by standard deviation of angular error) in the dynamic and stationary conditions during CVI stimulation that worsened when the stimulation was turned off.
Conclusions: Our preliminary findings suggest that the VCI has the potential to improve higher-level cognitive deficits in patients with bilateral vestibulopathy.
PPII:77 - Design of a Wearable Separated Interface Nerve Electrode Device for Rodents
Celia Fernandez Brillet1, Dale C Roberts2, Charles C Della Santina3, Gene Y Fridman3
1Johns Hopkins University, Department of Biomedical Engineering, USA
2Johns Hopkins University, Department of Otolaryngology–Head and Neck Surgery, USA
3Johns Hopkins University, Departments of Otolaryngology–Head and Neck Surgery and Biomedical Engineering, USA
Purpose: Previous work has shown the advantages of direct current (DC) over pulsatile stimulation due to its ability to excite, inhibit, and modulate vestibular pathways’ sensitivity. Those acute experiments were conducted using a separated interface nerve electrode (SINE) setup, which would be unsafe for chronic stimulation due to the production of chemical by-products that could alter pH levels at the tissue beyond safety limits.
Methods: We present a device that can safely deliver ionic DC for a limited duration. This safety duration is the time during which chemical by-products are still being generated but are kept away from the tissue. The system uses fine stainless steel mesh electrodes inserted into a chamber containing gelled artificial perilymph solution. The gel-filled reservoirs connect via silicone tubing to fine microcapillary tips, which interface with the vestibular nerve through canalotomies. The device’s safety duration was estimated by measuring pH changes in the tubes as a function of stimulation amplitude and duration. The device was tested on the bench to ensure that pH changes at the nerve interface remained within the acceptable safety criteria of <1 pH unit, avoiding adverse physiological effects. The circuitry is programmed wirelessly throughout experiments and reports real-time data to a controlling computer.
Results: The duration of safe stimulation decreased with increasing stimulation amplitudes. The device continuously stimulated the vestibular nerve of two free-roaming chinchillas with 10 µA of DC for 14 days and showed low variability in electrode impedance. Electrically-evoked vestibulo-ocular reflex and vestibulo-cervical responses were successfully elicited throughout the experiment and after its conclusion.
Conclusions: This self-contained device, powered by a small battery and designed to be easily positioned on a rodent head post, enables conducting chronic studies of DC safety. Our preliminary data shows the ability to stimulate the vestibular nerve with DC while maintaining a functional reflex pathway.
PPII:78 - Functional VOR in Bilateral Vestibulopathy: The Impact of Prolonged Continuous Stimulation via Vestibulocochlear Implant
Benjamin Volpe1, Bernd Vermorken1, Stan van Boxel1, Angélica Perez-Fornos2, Nils Guinand2, Elke Devocht1, Raymond van de Berg1
1Maastricht University Medical Center (MUMC+), Department of Otorhinolaryngology and Head and Neck Surgery, Division of Balance, Maastricht, The Netherlands
2Hôpitaux universitaires de Genève (HUG), Service of Otorhinolaryngology and Head and Neck Surgery, Department of Clinical Neurosciences, Geneva, Switzerland
Purpose: As part of the VertiGO-trial, this study investigates the impact of prolonged and continuous vestibular stimulation via a multichannel vestibulocochlear implant (VCI) on functional vestibulo-ocular reflexes (VOR) among individuals with bilateral vestibulopathy.
Methods: Nine subjects with bilateral vestibulopathy and sensorineural hearing loss were enrolled in the study and received a unilateral VCI. Following standard clinical CI rehabilitation, the VI was fitted and ready for activation. Functional testing consisted of dynamic visual acuity (DVA) testing on a treadmill at various speeds and the functional Head Impulse Test (fHIT) across three planes (LHRH, RALP, LARP). Testing spanned three weeks under continuous vestibular stimulation, exploring three paradigms: 1) modulation from a 50% dynamic range baseline, 2) modulation from a reduced baseline, and 3) baseline stimulation alone, with pre- and post-reference tests without VI stimulation.
Results: DVA and fHIT scores showed improvements among some participants, although these benefits were not observed universally. The relationship between found results and measured peak eye velocities, possible learning- or aftereffects of VI stimulation were examined.
Conclusions: Continuous and modulated vestibular stimulation through a VCI shows potential for enhancing functional VOR in patients with bilateral vestibulopathy, though its efficacy varies among individuals. These findings highlight the potential need for personalized stimulation strategies and/or optimization of suitable functional outcome measures. More importantly, extending research to include long term home-based stimulation within patients' own environments represents an essential next step in vestibular implant research. Such studies are crucial for demonstrating the device's effectiveness in daily life and advancing its clinical applicability.
PPII:79 - Improving hearing preservation in vestibular implant surgery using a hand-guided robotic drill?
Joost Stultiens1, Xinli Du2, Jérôme Waterval1, Nils Guinand3, Raymond van de Berg1
1Maastricht University Medical Center, Department of Otorhinolaryngology and Head and Neck Surgery, Maastricht, The Netherlands
2Brunel University, Department of Mechanical Engineering, London, United Kingdom
3Geneva University Hospitals, Department of Otorhinolaryngology and Head and Neck Surgery, Geneva, Switzerland
Purpose: In recent years, the feasibility of a vestibular implant for partially restoring vestibular function was shown. However, vestibular implantation can induce sensorineural hearing loss, while most patients with bilateral vestibulopathy have no severe hearing loss. When the semicircular canals are drilled open to facilitate electrode insertion, there is a risk of rupturing the membranous labyrinth, thereby opening the endolymphatic compartment. This may lead to hearing loss. When fenestrating with a force-sensing robotic drill, the change of drilling medium might be detected, to automatically stop when entering the canal. This way, the endolymphatic compartment might be protected. The purpose was to assess the feasibility of a hand-guided robotic sensing drill to fenestrate the semicircular canals without rupturing the membranous labyrinth. A secondary aim was to assess electrode insertion through the fenestrations.
Methods: On formalin-fixed cadaveric temporal bones, a mastoidectomy with exposure of the bony semicircular canals was performed. The hand-guided robotic drill was then used to create two fenestrations in each canal. Damage to the membranous labyrinth was evaluated using a surgical microscope. Attempts were made to insert a silicone dummy electrode through the fenestrations.
Results: Ten temporal bones (30 canals) were included. Fifty-four fenestrations showed no damage to the membranous labyrinth (19 in superior and posterior, 16 in lateral canals). In six cases, a technical issue related to drill bit fixation occurred. In 44/54 (81%) of cases, fenestrations were large enough for insertion of the dummy electrode.
Conclusions: The hand-guided robotic drill demonstrated promise in protecting the membranous labyrinth during canal fenestration, suggesting potential benefits for vestibular implantation in patients with residual hearing. Additionally, it might benefit vestibular interventions like semicircular canal plugging (such as for superior canal dehiscence or benign paroxysmal vertigo).
PPII:80 - Obstructions of the Semicircular Canals - Implications for Vestibular Implantation
Joost Stultiens1, Raymond van de Berg1, Marc van Hoof1, Vincent Van Rompaey2, Janny Hof1, Bernd Vermorken1, Benjamin Volpe1, Elke Devocht1, Angélica Pérez Fornos3, Alida Postma4, Vincent Lenoir5, Minerva Becker5, Nils Guinand3
1Maastricht University Medical Center, Department of Otorhinolaryngology and Head and Neck Surgery, Maastricht, The Netherlands
2Antwerp University Hospital, Department of Otorhinolaryngology and Head and Neck Surgery, Antwerp, Belgium
3Geneva University Hospitals, Department of Otorhinolaryngology and Head and Neck Surgery, Geneva, Switzerland
4Maastricht University Medical Center, Department of Radiology and Nuclear Medicine, Maastricht, The Netherlands
5Geneva University Hospitals, Department of Radiology, Geneva, Switzerland
Purpose: Inner ear imaging during patient selection for vestibular implantation may reveal potential semicircular canal obstructions. This can indicate possible surgical challenges. The purpose of this study was to investigate the relationship between preoperative imaging and surgical findings of obstructions in the semicircular canals and to design surgical approaches to deal with these obstructions.
Methods: Patients were enrolled from an ongoing clinical trial, evaluating a second-generation vestibulocochlear implant. They were included in the current study when preoperative imaging (high-resolution CT and MRI) indicated an obstruction in one or more semicircular canals, excluding the ampulla. Surgical procedures involved extensive bluelining of the canals during surgery to identify the course of the canal and locate possible obstructions. Subsequently, specific techniques were used to facilitate proper electrode positioning. Intraoperative assessment was conducted through microscopic inspection, postoperative evaluation was performed using CT scans.
Results: Three patients diagnosed with bilateral vestibulopathy due to DFNA9 were included. Preoperative imaging revealed absent or low-intensity T2-weighted MRI signals and normal CT densities in the superior semicircular canal, the posterior canal, or both canals, suggesting soft tissue obstructions. During surgery, a distinct 'whiteline' appeared instead of the typical blueline at these locations. Various surgical techniques were employed to address the obstructions. These included using a dummy electrode for probing, removing obstructive tissue, and creating a bypass fenestration. Ultimately, all electrodes were successfully implanted in the semicircular canal ampullae. Based on these experiences, a diagnostic and surgical guide was developed.
Conclusions: Obstructions in the semicircular canals can pose challenges during vestibular implantation surgery. However, the combination of preoperative imaging and intraoperative bluelining may aid identification of these obstructions. Consequently, appropriate surgical techniques can be applied to facilitate electrode insertion. A diagnostic and surgical guide to deal with obstructions of the semicircular canals during vestibular implantation was developed based on these experiences.
PPII:81 - The Vestibulocochlear Implant: Perceptual Responses
Benjamin Volpe1, Bernd Vermorken1, Stan van Boxel van Boxel1, Angélica Perez-Fornos2, Nils Guinand2, Elke Devocht1, Raymond van de Berg1
1Maastricht University Medical Center (MUMC+), Department of Otorhinolaryngology and Head and Neck Surgery, Division of Balance, Maastricht, The Netherlands
2Hôpitaux universitaires de Genève (HUG), Service of Otorhinolaryngology and Head and Neck Surgery, Department of Clinical Neurosciences, Geneva, Switzerland
Purpose: By directly stimulating the vestibular nerves, the vestibular implant (VI) aims to restore vestibular function. Previous studies show feasibility of the implant, but the perceptual responses to vestibular stimulations are not yet studied in detail. These responses might be important, because they play a role in fitting the VI. In this study, subject's perception during short, acute vestibular stimulation were explored to gain more insight in the implications of perception for fitting a VI.
Methods: Nine patients with bilateral vestibulopathy and sensorineural hearing loss enrolled in the study and received a unilateral implant. On multiple sessions, each vestibular electrode was repeatedly stimulated with two second pulse trains with increasing amplitude using a stepwise approach. After every pulse train, subjects were asked if stimulation was felt and if so, they were encouraged to elaborate and describe what they felt. Intensity of perception was noted using a custom visual-analogue-scale (VAS). Threshold (T) and upper comfortable limit (UCL) for vestibular stimulation were obtained. The electrical dynamic range (DR) was determined as the current ranging from T up to the UCL.
Results: Analysis of the results shows that quality of perception is variable between subjects and can be categorized in three different domains: auditory, vibration and movement. Furthermore, results show a stable VAS-score over time. Threshold is mostly determined based on the start of perception, in some cases eye movements precedes perception. UCL is mostly determined based on VAS, unless facial nerve stimulation occurs first. The DR is stable over time in most patients, although variations in UCL exist.
Conclusions: This study gave insight in the intensity and type of self-reported perception in response to electrical vestibular stimulation with a VI. These findings give valuable input on how to fit a VI since perceptual responses play an important role in determining the DR available for stimulation.
PPII:82 - Thresholds as a Measure to Identify Crosstalk in Cochleo-Vestibular Implant Stimulation
David Lanthaler1, Andreas Griessner1, Viktor Steixner1, Julie Corre2, Maurizio Ranieri2, Samuel Cavuscens2, Gautier Grouvel2, Clemens M. Zierhofer1, Angélica Pérez-Fornos2
1University of Innsbruck, Department of Mechatronics, Austria
2Geneva University Hospitals and University of Geneva, Cochlear Implants Center, Switzerland
Purpose: Due to the anatomical proximity of the cochlea and the vestibular system, understanding the electrical crosstalk between the different stimulation electrodes is essential for the successful fitting and operation of combined cochleo-vestibular implants. We present first results of a case study to investigate cochleo-vestibular crosstalk during combined electrical stimulation.
Methods: To investigate these interactions, the perception of single electrode stimulation in the cochlea and the vestibular system were determined within three implant recipients. As our main measure, we used the detectable threshold of a probe burst signal with and without a perturbation signal on either an electrode in the same organ or on an electrode in the other end-organ. Subjects were asked to identify one out of three stimulation bursts that was augmented with a probe signal. The detection thresholds for the one probe signal were determined with a three-alternative-forced-choice (3AFC) adaptive staircase procedure. This procedure was used to systematically increase or decrease the amplitude of the probe signal until the threshold value settled. The final threshold values were obtained by averaging over the last reversals in the 3AFC procedure.
Results: The results are subject-dependent and not easily generalized, however there is an indication in all subjects that there are interactions within the vestibular organ that increase the detectable thresholds when vestibular electrodes are used for both probe and perturbation signal. We did not find a uniform tendency for interactions between single electrode stimulations across separate end-organs.
Conclusions: The presented study provides threshold data from a small group of subjects. The results suggest a noticeable interaction for electrodes within the vestibular organ, but the variability of the overall results incentivizes future studies in order to better understand on how thresholds are influenced by different parameters, e.g., electrode positions or anatomical differences.
PPII:83 - Vestibular Implant Stimulation Pause Detection–Implications for Design of Physiologic Alerts Signaling Battery Depletion
Celia Fernandez Brillet1, Margaret R Chow2, Andrianna I Ayiotis1, Charles C Della Santina3
1Johns Hopkins University, Department of Biomedical Engineering, USA
2Labyrinth Devices, LLC, USA
3Johns Hopkins University, Departments of Otolaryngology–Head and Neck Surgery and Biomedical Engineering, USA
Purpose: To encode head rotation both toward and away from the implanted ear, the unilateral Labyrinth Devices Multichannel Vestibular Implant (MVI) may modulate stimulation above and below a nonzero tonic level of stimulation representing zero head velocity. Sudden cessation of stimulation due to battery depletion could cause uncomfortable experiences such as vertigo. To guide the design of a physiologic alert system to inform a patient that the device’s battery is nearly depleted, we investigated the MVI users’ ability to detect stimulation pauses of varying duration.
Methods: Nine participants implanted unilaterally as part of the MVI Early Feasibility Study (NCT02725463) were tested after ≥6 weeks of acclimation to MVI stimulation. While at rest, stimulation pauses of 1–300 ms were introduced at random times averaging 5 seconds apart. Subjects pushed a button whenever a change in stimulation was detected. We fit cumulative Gaussian distributions to detection probability vs. pause duration curves. We retested each participant in a distraction condition, in which the experimenter and VI recipient conversed for the entirety of the test.
Results: In the quiet condition, stimulation pause detection thresholds ranged from 15–67 ms, with a median of 40 ms. Distractions increased detection thresholds to 62 ms (range 30–82 ms). Response latencies from stimulation pause onset decreased as a function of pause duration in all but one subject and were almost always ≤1 s.
Conclusions: These results suggest that there is no single optimal stimulation pause duration to alert MVI subjects of battery depletion. Instead, each person has a detection threshold that could be too short or too long for other subjects. To accommodate this range of detection thresholds, devices should ramp up stimulation pause duration and frequency rather than rely on a single uniform duration. This ramping should be slow enough to be perceived by different users at different detection thresholds.
PPII:84 - Vestibulocochlear implant modulation affects self-motion perception and the VOR in bilateral vestibulopathy
Bernd Vermorken1, Benjamin Volpe1, Stan van Boxel1, Nils Guinand2, Angelica Perez Fornos2, Elke Devocht1, Raymond van de Berg1
1Department of Otorhinolaryngology and Head and Neck Surgery, Division of Balance Disorders, School for Mental Health and Neuroscience (MHENS), Maastricht University Medical Centre, Maastricht, The Netherlands
2Division of Otorhinolaryngology Head and Neck Surgery, Department of Clinical Neurosciences, Geneva University Hospitals, Geneva, Switzerland
Purpose: This study evaluates the effectiveness of multichannel vestibulocochlear implant (VCI) stimulation in enhancing self-motion perception and vestibulo-ocular reflexes (VOR) among patients suffering from bilateral vestibulopathy.
Methods: Nine cases with bilateral vestibulopathy and ipsilateral severe sensorineural hearing loss were implanted with the newest VCI prototype. After standard CI rehabilitation, the vestibular electrodes were fitted and activated. The effect of VCI stimulation on self-motion perception and VOR was evaluated using different stimulation paradigms: 1) modulation from a baseline stimulation at 50% of the dynamic range, 2) modulation from a lowered baseline stimulation level, 3) baseline stimulation only. Self-motion perception thresholds were determined on a hydraulic platform, using six rotations in yaw, pitch and roll. VOR was recorded for both low and high frequency head rotations, using sinusoid motion profiles on the rotatory chair and the video head impulse test, respectively.
Results: VCI fitting and initial activation elicited eye movements and movement perceptions consistent with Ewald’s law. Prolonged modulated stimulation resulted in decreased self-motion perception thresholds in the yaw plane, enhanced VOR gain and a reduction in corrective saccades in the majority of cases. Conversely, baseline stimulation only did not show improved self-motion perception thresholds or VOR restoration.
Conclusions: VCI modulation demonstrated promising outcomes in self-motion perception and VOR. Long-term home-use stimulation is needed to demonstrate the potential effect of VCI modulation on gaze stabilization and movement perception in daily life.
27. Others
PPII:85 - A preliminary study of the treatment of chronic tinnitus in menopausal women
Xin Ma
1
1Peking University People's Hospital
Purpose: To explore the efficacy of the menopause related tinnitus with hormone treatment and the possible pathogenesis of menopause related tinnitus.
Methods: (1) From April 2016 to October 2016, 59 patients who were diagnosed with menopausal syndrome in the menopause clinics of Beijing Shijitan Hospital were enrolled in our study and carried out questionnaire investigation. According to the presence or absence of tinnitus, they were divided into two groups. Age, BMI, menopausal KMI scores, estrogen levels, menopausal symptoms and other possible risk factors of tinnitus were statistically analyzed. (2) Among those 18 cases with tinnitus, according to the patients´ wishes, they were divided into hormone therapy group and untreated group. Compared two groups of patients age, BMI levels, menopause KMI scores, degree of tinnitus, and carried on the statistics analysis. Follow-up of 3 months, analyze the tinnitus curative effect.
Results: (1) The results indicated that significant correlativity existed between the incidence of headache and occurance of tinnitus while other risk factors including insomnia showed no statistical association. (2) There were no statistical differences between the two groups of patients with tinnitus about age, BMI levels, menopause KMI scores and degree of tinnitus. After follow up for 3 months of the two groups, there was no change in the untreated group. Among 9 patients in the treated group , tinnitus disappeared in 5 patients, there was no change in 4 patients .
Conclusions: Menopause related tinnitus was an independent menopausal symptom rather than secondary to insomnia of perimenopause. Tinnitus is caused by the interactions among multifactors in which headache plays an important role in the pathogenesis of tinnitus. we can try menopause hormone therapy for the right tinnitus patients.
PPII:86 - A survey of knowledge and clinical practice of Thai physical therapists on vestibular rehabilitation
Alongkot Emasithi1, Areewan Inthamanon1, Krittanai Teeratamtada1
1Department of Otolaryngology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
Purpose: Vestibular rehabilitation (VR) is a beneficial and efficacious treatment for patients with vestibular dysfunction. There are a great number of physical therapists who practice VR worldwide, but it has received little attention in Thailand. The study aimed to investigate the current situation of knowledge and clinical experience in VR among Thai physical therapists.
Methods: An online self-administered survey questionnaire was conducted from January to March, 2024. The questionnaire consisted of 2 sections: demographic information and current status of Thai physical therapists regarding VR.
Results: A total of 178 Thai physical therapists answered the questionnaire. About 72% of them studied VR from their professional degree programs, or attended workshops. Majority of them (87.1%) are interested in receiving additional VR education. Seventy-nine physical therapists indicated that they have clinical experience in VR, but merely 10 of them have more than 5 years of experience. More than half of them, however, still lack of confidence in diagnosis and treatment of BPPV. All of them want to further improve their knowledge and skills through workshops and clinical training.
Conclusions: At present, VR is considered as a new knowledge and skill for Thai physical therapists. Raising an awareness of necessity of VR education is urgently required for Thailand.
PPII:87 - An Audit of Documentation Standards for Patients with Acute Vertigo in the Emergency Department
David Herdman1, Hena Ahmad2, Arun Pajaniappane1
1St Georges University Hospital NHS Foundation Trust, Audiovestibular Department, UK
2St Georges University Hospital NHS Foundation Trust, Neurology Department, UK
Purpose: Acute dizziness or vertigo is a common presentation in the emergency department (ED), but it is not clear to what extent clinicians are already following expert guidelines.
Methods: Two authors (DH & AP) completed a retrospective audit of 200 consecutive electronic records from patients who presented to the Emergency Department of a University Hospital in London, UK, prior to the implementation of a quality improvement project.
Results: A total of 191 patients (mean age 50 ± 17 years) met the inclusion criteria. Common investigations included blood testing (78%), ECG (59%), CT head (28%), MRI (12%), chest X-ray (6%), and CT-angiography (3%).
Documentation of the presence and/or characteristics of nystagmus was inadequate, with 54% unclear or absent documentation, and 7% suggestive of peripheral and 2% of central nystagmus. The Head-Impulse-Nystagmus-Test-of-Skew (HINTS) was performed in 21% of cases, and hearing evaluation considered in 29%. The Dix-Hallpike test was conducted in only 16% of cases.
Only 7% of cases had sufficient documentation for clinical judgement, with 14% demonstrating ‘meaningful errors’ in test selection or interpretation (such that the recorded description conflicted with the diagnosis and/or management). Common errors included misclassifying potentially central signs (e.g., hearing loss or normal head impulse). Correct diagnoses were made in only 6% of cases, with another 6% being meaningfully incorrect whilst the majority (88%) had insufficient documentation.
Conclusions: Although reported imaging utilisation is low, unnecessary tests are still performed, and clinicians continue to make therapeutic decisions based on misunderstandings that are contrary to expert clinical guidelines. The recommended bedside assessment is rarely used, and documentation standards often prevent meaningful inference. These findings underline the importance of focused education and enhanced record-keeping. Using an electronic proforma could be useful.
PPII:89 - Cases of Cardiovascular Diseases Visited the Otolaryngology of the Kochi Health Sciences Center with Dizziness
Akira Doi1, Asuka Nagao1, Kennichi Kozakura1, Yukari Nishimori2, Chiaki Aoji2, Keiko Tsutsui2, Yuka Hirai2, Miyuki Ito2, Risa Yamasaki2, Yuki Yoshimura3, Katsuto Yamamoto3
1Division of Otolaryngology, Kochi Health Sciences Center, Japan
2Clinical laboratory, Kochi Health Sciences Center, Japan
3Department of cardiology, Kochi Health Sciences Center, Japan
Purpose: 当院の耳鼻咽喉科を受診し、原因が循環器疾患と判明しためまいの症例について報告します。
Methods: ターゲット: 調査対象は、2018年4月から2024年3月までにめまいを訴えて当院の耳鼻咽喉科を受診した循環器疾患の患者さんです。レビューされたポイント: 心血管疾患が疑われる症例数、発症時期、耳鼻咽喉科でめまいと診断された原因、循環器疾患治療によるめまいの予後について検討した。
Results: 11例が心血管疾患と診断された。心血管疾患が疑われる理由は、意識喪失発作が3例、不整脈が2例、労作困難が2例、心房細動が1例、心窩部痛が1例、心電図異常が1例であった。2例はもともと循環器内科を受診した患者であった。心血管疾患が疑われる時期は、初診時が1例、疾患中が6例(1ヶ月以内1例、3ヶ月以内4例、6ヶ月以内1例)であっためまい診断時、不安定血圧が7例、姿勢性起立性頻拍症候群が1例、脳幹運動失調が1例、メニエール病が2例、BPPVが1例、その他の耳原性が3例であった(複数の理由、いずれもカウント)。治療の優先順位は心血管疾患に与えられました。めまいの予後は、改善が7例、変化が2例、心疾患による死亡が2例であった。
Conclusions: 心血管疾患の疑いを抱かせる所見は、しばしば3ヶ月以内に現れた。試験中に情報を見逃さないでください。この研究では、11例中7例が心血管疾患の治療で改善されました。この結果は、めまいのいくつかの症例が心血管疾患の治療を必要とすることを示唆しています。
PPII:93 - Dizziness and vertigo sick leave before and after insurance restrictions – a Swedish nationwide register study
Katarina Zborayova1, Marie-Louise Barrenäs1, Gabriel Granåsen2, Kevin Kerber3, Jonatan Salzer4
1Department of Clinical Science, Otorhinolaryngology, Umeå University, Umeå, Sweden
2Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
3Department of Neurology, Ohio State University, Columbus, OH, USA
4Department of Clinical Science, Neurosciences, Umeå University, Umeå, Sweden
Purpose: Dizziness/vertigo can be disabling symptoms, however little is known about absence from work due to dizziness/vertigo. We used a Swedish nationwide work-sickness register to describe the vertigo/dizziness sick leave prevalence and duration stratified by diagnoses.
Methods: From 2005-2018, through Swedish nationwide registers we identified individuals aged 16–64 years who were sickness absent >14 consecutive days – minimum register threshold – due to vertigo/dizziness ICD10 codes: vestibular codes, H81.x; ataxia G11.x; and unspecific codes R26 (abnormality of gait), R27 (abnormality of coordination), and R42 (Dizziness). We described the demographics, prevalence, Sickness Cash Benefit Rate and sick leave duration.
Results: We identified 52179 vertigo/dizziness sick-leave episodes >14 days in 45353 unique individuals. The most common ICD10 diagnoses were: unspecified diagnoses [72% (n=37741)], vestibular H-diagnoses [27% (n=14083)], and Ataxias [ 1% (n=355)]. The most common specific vestibular codes were Benign paroxysmal positional vertigo (BPPV) 9% (n=4929) and Vestibular neuritis 9% (n=4762). The median duration on top of the 14 qualifying days was 17 days (IQR 7–47). For unspecified dizziness but not vestibular nor ataxia diagnoses, Sickness Cash Benefit Rate increased between 2005 and 2007 and decreased between 2008 and 2010, following national trends in Sweden.
Conclusions: The majority of vertigo/dizziness sick leave episodes were caused by unspecified diagnoses. BPPV, a curable condition, was a commonly used diagnosis on sick leave certificates. The fluctuations in Sickness Cash Benefit Rate for unspecific dizziness diagnoses following national trends might be explained by changes in national regulations rather than changes in disease-specific incidences.
PPII:94 - Evaluating AI Chatbot Responses to Hypothetical Patient Inquiries Regarding Vertigo
Preetham Bachina1, Arun Venkatesan1, John Probasco1, Barney Stern1, Kemar Green1
1Johns Hopkins University School of Medicine, Department of Neurology, United States of America
Purpose: A series of recent studies assessing the accuracy of information provided by Large Language Models (LLMs) have been performed in various fields of medicine and have highlighted both their generally high accuracy and capability to spread misinformation. Our investigation aims to shed light on the potential of AI chatbots as informative agents for answering potential patient questions regarding dizziness/vertigo.
Methods: We created a set of 10 questions spanning the realms of etiology, diagnosis, treatment, and prevention centering around symptoms of vertigo. The questions were queried 3 separate times into 2 publicly available AI chatbots: ChatGPT 3.5 and Google Bard. 3 independent neurologists who were blinded as to which chatbot generated each response rated each of the 6 responses as either “Appropriate”, “Inappropriate” or “Incomplete”. A simple majority across the 3 reviewers was used to determine the final rating of each response; if a majority did not exist, the response was considered to have a rating of “Inconsistent”.
Results: Of the 60 AI chatbot responses reviewed for the queries 10 questions, 32 (53.33%) were deemed to be appropriate. Though a noticeable difference was observed in the rate of “Inappropriate” ChatGPT responses (16.67%) compared to Bard responses (6.67%, p = 0.081), no significant differences were observed between the overall response classifications across the possible ratings. Moreover, when each question was asked 3 times per model, the rating of responses across the multiple queries was consistent for 9 out of the 10 questions. This suggests a general reproducibility in the quality of responses, both appropriate and inappropriate.
Conclusions: AI chatbots will likely transform the manner in which patients query and consume information pertaining to their symptoms. While chatbots may on average provide appropriate responses to queries about vertigo, a nontrivial proportion are either incomplete or inappropriate and require further characterization to prevent the spread of misinformation.
PPII:95 - Existence of Proprioceptive Cervicogenic Dizziness
Tarifur Rahman1, Raj Nandi1
1Department of Audiovestibular Medicine, Royal National ENT & Eastman Dental Hospitals, University College London Hospitals NHS Foundation Trust, United Kingdom
Purpose: Evidence for Proprioceptive Cervicogenic Dizziness
Methods: Systematic review of literature
Results: A systematic search of medical literature was carried out using EBSCOhost and PubMed. 17 articles were identified to be specifically related to Cervicogenic Dizziness. Of these 7 were reviews, 4 were cross-sectional studies. Rests were longitudinal cohort study (1), clinical and immunohistochemical study (1), literature search (1), study on diagnostic parameters (1), study on neck muscle vibration (1) and report (1). Of the articles identified, 14 articles were selected for review for our purpose and 3 were excluded as they were not specifically related to cervical proprioception. Of the reviewed articles the common findings were as follows.There is a clear theoretical basis for the ‘Proprioceptive Cervicogenic Dizziness’ which is also supported by evidence. If neck stiffness/pain affects the range of neck movement, there should be a mismatch between the efference-copy signal about the intended head movement and the actual re-afference. Even in absence of restricted neck movement, long term neck pathology can derange proprioception of neck muscle, tendon, joints which can cause sensory mismatch with the vestibular and visual input in the multisensory integration process within the central nervous system affecting the vestibulo-spinal and vestibulo-ocular reaction. Evidently, a positive correlation between neck pain and dizziness justifies that they are interlinked. There is also evidence of Ruffini corpuscles to have a key role in the dizziness pathogenesis in cervical degenerative disease and interestingly, surgical elimination of cervical degenerative disease cures the associated dizziness.
Conclusions: This literature review shows that Proprioceptive Cervicogenic Dizziness exists. It is therefore suggested that robust diagnostic criteria are developed as patients are otherwise likely to suffer without having a tenable diagnosis.
PPII:98 - Impact of Skeletal Muscle Mass Loss on Patients with Dizziness
Hirofumi Ogihara1, Tomohiko Kamo2, Masato Azami3, Ryozo Tanaka4, Takumi Kato5, Reiko Tsunoda5, Hiroaki Fushiki5
1Department of Rehabilitation, Faculty of Health Sciences, Nagano University of Health and Medicine, Japan
2Department of Physical Therapy, Faculty of Rehabilitation, Gunma Paz University, Japan
3Department of Physical Therapy, Faculty of Health Sciences, Japan University of Health Sciences, Japan
4Department of Physical Therapy, Faculty of Health Sciences, Mejiro University, Japan
5Otolaryngology, Mejiro University Ear Institute Clinic, Japan
Purpose: Skeletal muscle mass has been reported to be associated with physical function, balance, and activities of daily living in various diseases. However, few studies have analyzed skeletal muscle mass in patients with dizziness. The purpose of this study was to investigate the relationship between Skeletal Muscle Mass Index (SMI) and the Dizziness Handicap Inventory (DHI) in patients with chronic dizziness.
Methods: Eighty-eight patients with dizziness were included in this study. Age, gender, Body Mass Index (BMI), grip strength, walking speed, SMI, DHI, Dynamic Visual Acuity (DVA), Timed Up and Go test (TUG), Functional Gait Assessment (FGA), modified Clinical Test of Sensory Interaction in Balance (mCTSIB), Activities-specific Balance Confidence scale (ABC scale), and Hospital Anxiety and Depression Scale (HADS) were investigated. Multiple regression analysis was performed with DHI as the dependent variable and SMI and other variables as independent variables. To exclude the influence of gender differences in the SMI, analyses were conducted separately for men and women.
Results: BMI, SMI, and ABC scale (β= 0.580, -0.632, -0.721, p<0.05) were significantly associated with DHI in men. SMI, ABC scale, and HADS_Anxiety (β= -0.381, -0.289, 0.348, p<0.05) were significantly associated with DHI in women.
Conclusions: Skeletal muscle mass in patients with dizziness was found to be associated with DHI. As in the elderly, skeletal muscle loss in patients with dizziness may be associated with limitation of activities of daily living. It is suggested that assessing skeletal muscle mass is useful in the evaluation of patients with dizziness.
PPII:99 - Investigating the role of the vestibular system in neurodevelopmental disorders: a study protocol
Emmely Van Acker1, Ruth Van Hecke1, Frederik Deconinck2, Ingeborg Dhooge3, Andy Beynon4, Lynn Bar-On1, Roeljan Wiersema5, Leen Maes1
1Ghent University, Department of Rehabilitation Sciences, Belgium
2Ghent University, Department of Movement and Sports Sciences, Belgium
3Ghent University Hospital, Department of Otorhinolaryngology, Belgium
4Radboud University Nijmegen Medical Center, Otorhinolaryngology Department, Netherlands
5Ghent University, Department of Experimental Clinical and Health Psychology, Belgium
Purpose: School-aged children diagnosed with neurodevelopmental disorders (NDDs), such as Developmental Coordination Disorder (DCD), Attention Deficit/Hyperactivity Disorder (ADHD), and Autism Spectrum Disorder (ASD), often face a wide range of challenges in their daily lives including postural instability, sensory integration issues, and difficulties with both gross and fine motor skills. Despite the recognized contribution of the vestibular system to motor abilities, research focusing on motor performance within the NDD population frequently overlooks this aspect. To explore this neglected topic, a cross-sectional study protocol was developed.
Methods: This comprehensive protocol entails a vestibular and sensorimotor test battery, evaluating all five components of the vestibular system alongside motor competence, balance skills, and sensory integration. Supplementary screenings are included to control for potential confounding factors, such as visual acuity and hearing status. The protocol will be conducted on two cohorts of school-aged children (6-12 years old): an NDD group (n=130) and a group of typically developing peers (n=130), matched for age and sex.
Results: Given the nature of this article, results are pending.
Conclusions: This project aims to explore the integrity of the vestibular system in children with NDDs and investigate how the vestibular function influences the sensorimotor skills of these children. By shedding light on the underlying mechanisms of NDDs, this study has the potential to improve diagnostic and rehabilitation approaches. Approval for this project was granted by the ethics committee of Ghent University Hospital.
PPII:100 - Occurrence of Delayed BPPV in Patients with Sudden Sensorineural Hearing Loss with Vertigo
Sung Il NAM1, Seung Yeon YU1
1Department of Otorhinolaryngology, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
Purpose: This study aims to analyze the initial patterns of nystagmus, changes in nystagmus and results of vestibular function tests in patients diagnosed with idiopathic SSNHL accompanied by vertigo.
Methods: A retrospective study on unilateral SSNHL with vertigo (SSNHL_V) was conducted using patients' histories and audiometry at our ENT department from May 2018 to June 2023. It included patients who reported dizziness and had abnormal nystagmus on VNG, categorizing them into irritative, paretic, or BPPV-related nystagmus groups. Chi-square and Fisher’s exact tests were used for statistical analysis.
Results: A total of 142 patients were finally included in the study. 40 patients (28.2%) showed irritative nystagmus, 36 patients (25.4%) showed paretic nystagmus and 66 patients (46.5%) were diagnosed with BPPV in the initial VNG performed within 48 hours of onset. The posterior canal was the most commonly affected in concurrent BPPV, followed by horizontal canal BPPV and multicanal BPPV. In the irritative nystagmus group, 17 patients (42.5%) showed delayed onset BPPV within a week of their initial SSNHL_V diagnosis. However, in the paretic nystagmus group, no BPPV were observed within a week, showing a statistically significant difference (p<0.001). There was no statistically significant difference in initial hearing impairment and final hearing recovery after treatment among the three groups.
Conclusions: Patients with SSNHL_V who showed irritative nystagmus in the early stages of hearing loss were more likely to develop delayed BPPV compared to those with paretic nystagmus. In cases of SSNHL_V with irritative nystagmus, meticulous observation is deemed imperative to clinicians
PPII:101 - Optimality conditions for gaze stabilization
Stefan Glasauer1, Hans Straka2
1Brandenburg University of Technology Cottbus-Senftenberg, Computational Neuroscience, Germany
2Ludwig-Maximilians-Universität München, Dept. of Biology II, Germany
Purpose: During passive head rotations, gaze is stabilized via the vestibulo-ocular reflex (VOR) and the optokinetic response (OKR) by counter-rotation of the eyes. A perfect compensation of head rotation would require the eyes to move exactly opposite to the head with a unity gain factor. While gain factors close to unity are found in young healthy humans, in the elderly, in patients with vestibular deficits, and in many vertebrate species, gain factors lower than unity are found. Here we aim to elucidate possible reasons.
Methods: We assumed that low gains are not a deficiency but constitute an adaptation to other limitations of the sensorimotor systems involved. We used computational modelling of VOR and OKR to distinguish different possible reasons, based on the idea that gaze stabilization should depend on sensorimotor uncertainty (noise) in the system, but also other factors such as possible species-dependent optimization goals, or, in the case of OKR, neuronal delays or uncertainty about the cause of optic flow.
Results: We previously suggested that low VOR gains in Xenopus tadpoles are an optimal adaptation to high sensorimotor noise (Glasauer & Straka 2022) with gaze stabilization minimizing retinal image slip. In humans, an alternative stabilization goal could be to maintain foveal alignment. However, comparison of model simulations with human data suggests that even in humans, the VOR aims to minimize retinal slip. The OKR in lower vertebrates could be governed by a simple feedback circuit requiring gain limitations due to neuronal delays. In higher vertebrates, OKR involves internal feedback loops allowing higher gain factors, which, however, would also be limited by sensorimotor noise.
Conclusions: Model simulations suggest that the VOR minimizes retinal image velocity in humans and lower vertebrates, requiring low gain values with high sensorimotor noise. The same could be true for the OKR, but the experimental data are not yet conclusive.
PPII:102 - OTONEUROLOGICAL STUDIES IN THE PATIENTS WITH POST-TRAUMATIC VERTIGO
JORGE SAID MARTINEZ
1
1GABINETE DE NEUROFISIOLOGIA OTOLOGICA, CIUDAD DE MEXICO, MEXICO
Purpose: Accidental head injury and its sequalae constitute a major medical problem in Europe and America in these days. In 2020 in USA was reported a 3.6% incidence of head injury.
Methods: One hundred fifty neurotological patients has been investigated for posttraumatic vertigo as well as for hearing problems from 2020 to 2023.Clinical examination and laboratory tests were performed in all patients. We analyzed statistically the tinnitus, vertigo, hearing loss, type of trauma, nystagmus frequency, time elapse since trauma and slow phase velocity (SPV).
Results: The most frequency symptom reported was vertigo 73.3%, followed by lift sensation 46.6% and tilting and falling 26.6% both, and tinnitus 40% .
Conclusions: Post traumatic vertigo was found more frequently in male patients (ratio 2:1), the most common symptom was vertigo, lift sensation and falling, the compurarized electronystagmography and craniocorpography was a helpful tests in the diagnosis of central and peripheral lesions of the vestibular system which are secondary to head trauma.
PPII:103 - Physiotherapist Beliefs and Practice of Vestibular Rehabilitation Therapy in Egypt
Heather Fortuine1, Pretty Zakadan2
1Concordia University Wisconsin, Department of Rehabilitation Science, USA
2University of Hertfordshire-Hosted by Global Academic Foundation , Physiotherapy Program School of Health and Social Work, Egypt
Purpose: Vestibular rehabilitation (VR) is an important area of practice for physical therapists (PTs) globally. Little is known about the practice of VR among PTs in Egypt. This study investigated the current beliefs and practices related to VR among licensed PTs in Egypt.
Methods: A 28-question online survey was distributed to PTs practicing in Egypt. Questions addressed background, opinions on VR practice, and specifics of VR assessment and treatment. Descriptive and inferential statistics were used to analyze results.
Results: Of 367 responses, over 90% believed that PTs in Egypt are capable of VR practice. Nearly 40% reported VR as part of their PT practice, with higher levels of education associated with VR practice (p=0.04). Sixty-seven percent of practitioners believe they are required to obtain physician referrals prior to seeing patients for VR. Typical VR equipment was not used by 39.4% of VR practitioners. PTs practicing VR in Egypt reported they were not using or unaware of traditional treatments for benign paroxysmal positional vertigo (BPPV) including: Gufoni/Casani maneuvers (80.0%), canalith repositioning maneuver (60.0%), and the Epley maneuver (53.3%).
Conclusions: This survey offers an initial understanding of VR beliefs and practice among PTs in Egypt. Overall confidence in VR skills and knowledge is high, though most respondents were younger PTs with <5 years of experience in VR. Areas for growth include lack of specialized equipment, limited awareness of assessments and interventions, and the need to prioritize VR in entry-level curricula.
PPII:104 - Post COVID burden on neurotological service: our experience
N Kharytaniuk1, R Nandi1
1Department of Neuro-otology, Royal ENT and Eastman Dental Hospitals, University College London Hospitals NHS Foundation Trust, London, UK
Purpose: The array and prevalence of post-COVID sequelae are wide and well documented. Previous reports describe increased presentation of patients to audiological and neuro-otological services, following COVID infection, predominantly with dizziness, and with a short follow-up period. Our study aim was to review the symptoms with which patients presented to our services in the post-COVID era over a 2-year period and describe patients’ outcomes.
Methods: This was a retrospective review of prospectively collected data performed as part of clinical service evaluation. Anonymised data were collected, and analysed using SPSS statistical package (v29, IBM Corp). We reviewed medical records of adult patients (18 ≥ years-old) with audiovestibular symptoms following COVID infection or vaccination, and presenting between December 2021 – March 2024.
Results: Data on seventy patients were analysed (49 females, 70%); mean (SD) age 54 (14) years. Thirty-eight (54%) patients were new to the service. Sixty-six (94%) patients had confirmed COVID illness; 12 (17%) patients reported symptoms having been triggered or exacerbated after COVID vaccine. The most-to-least common symptoms (n; %) were: tinnitus (57; 81%), dizziness (55; 79%), hearing difficulties (42; 60%) and hyperacusis (29; 41%). The most common diagnoses at clinic review were vestibular migraine (31; 44%) and peripheral vestibular dysfunction (20; 29%); tinnitus only was present in 7 (10%) patients. Symptoms had resolved prior to clinic review in 9 (13%) patients.
Conclusions: Patients may have a range of neuro-otological symptoms post-COVID or present with an exacerbation of existing ones, of which vestibular migraines, peripheral vestibular dysfunction and tinnitus are likely to be most common.
PPII:105 - Psychometric properties of the Vertigo Symptom Scale–Short Form in a Swedish population with Acute Vestibular Syndrome
Solmaz Surano1, Erik Faergemann1, Gabriel Granåsen2, Jonatan Salzer1
1Department of Clinical Sciences, Neurosciences, Umeå University, Umeå, Sweden
2Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
Purpose: This study aimed to translate and cross-culturally adapt the VSS-SF for the Swedish population and modify it for acute vestibular syndrome (AVS) assessment.
Methods: The VSS-SF was adapted and evaluated in 86 patients with AVS across two phases: within 7 days of symptom onset (modified acute scales) and after six weeks of rehabilitation (standard scales). Psychometric testing of the VSS-SF assessed structural validity, internal consistency, and test-retest reliability. 54 matched healthy controls were included for comparative analyses.
Results: Both versions of the scales demonstrated a clear two-factor structure related to vertigo-balance (VSS-V) and autonomic-anxiety (VSS-A) subscales. In the acute scales, 13 items loaded clearly on these dimensions with no cross-loading, while the standard scales showed two items cross-loading. Internal consistency was high across both versions; the standard version’s Cronbach’s alpha ranging 0.865–0.758, the acute version ranging 0.818-–0.845 for the VSS-SF and VSS-V respectively, and 0.502 for the VSS-A subscale. Discriminative ability was excellent in the acute scales (area under the curve VSS-SF: 0.978, VSS-V: 0.998) and acceptable in the standard scales. A good test-retest reliability was shown for the standard VSS-SF and VSS-V subscale (intraclass correlation coefficient of 0.84 and 0.83 respectively) and satisfactory for the VSS-A subscale (0.72).
Conclusions: The study validated a two-factor structure for both standard and acute VSS-SF versions, correlating with vertigo-balance and autonomic-anxiety. The acute version effectively identified dizziness early, especially for vertigo-balance, while the standard version maintained acceptable discrimination post-rehabilitation. Yet, the autonomic-anxiety subscale showed weaker psychometric properties.
PPII:106 - Smartphone-Assisted Nystagmus Recording System to Record Vertigo Attacks Anytime, Anywhere
Hiroaki Fushiki1, Tatsuaki Kuroda2, Kazuhiro Kuroda2, Masao Noda3, Yumi Dobashi1, Hiroyuki Sakazaki1, Reiko Tsunoda1
1Department of Otolaryngology, Mejiro University Ear Institute Clinic, Japan
2Kuroda Ear, Nose and Throat Clinic, Japan
3Department of Otolaryngology, Jichi Medical University, Japan
Purpose: The recent widespread adoption of smartphones and tablet devices, coupled with advances in data communication technology, has resulted in a paradigm shift in the treatment of dizziness. External factors such as COVID-19 have further accelerated this transformation. In our pursuit of telemedicine and online medical care for dizziness, we have developed products and services for each stage of the treatment process. Many patients face challenges in accessing medical facilities during severe vertigo episodes. When symptoms have subsided by the time of their appointment, clinical findings such as nystagmus or other symptoms may be absent. In this study, we introduce a smartphone application designed to capture eye movements during vertigo attacks, enabling recording at any location.
Methods: This novel application enables patients to easily record their eye movements and head positions. In addition, the application is designed to mitigate the nystagmus suppression caused by fixation. For more reliable eye movement recordings, patients can use cardboard goggles specially designed to hold the smartphone.
Results: Much like an infrared CCD camera, an iPhone using this application successfully captured the subtle peripheral vestibular nystagmus of a vertigo patient.
Conclusions: This smartphone application is a highly effective tool in the treatment of vertigo. The introduction of this nystagmus monitoring system could potentially improve the quality of vertigo treatment, promote medical collaboration, and give patients peace of mind in their care.
PPII:107 - The Dutch Dizziness Classification
Agali Mert1, Simon Geerse2, Tjasse Bruintjes3
1Mert Medical, Rehabilitation Medicine, The Netherlands
2Treant, ENT, The Netherlands
3Gelre ziekenhuizen, ENT, The Netherlands
Purpose: The first objective was to propose a new definition of dizziness that includes the sensory, functional and emotional aspects of the sensation. The second objective was to classify dizzy patients taking into account the participatory and psychosocial impact of dizziness on general functioning.
Methods: Dizziness is a common symptom and has an extensive differential diagnosis. Yet, there is no consistent description or definition of what dizziness actually is. This inconsistency is further compounded by the multi-factorial nature and the inter-individual symptom-evolution of dizziness. Dizziness has in this regard many similarities with pain as a symptom and hence the definition of pain was contrasted with dizziness. In 2005 the Dutch Workgroup of Pain rehabilitation proposed four criteria to classify the complexity of pain with respect to the contribution of psychological and social factors to the levels of perceived disability. Both definition and classification were used as a model to classify for the complexity of dizziness.
Results: The new definition of dizziness: “Dizziness is a subjective, unpleasant sensory and emotional experience associated with actual or potentially harmful changes in the position of the body and/or head, in relation to gravity and/or the environment, or is described in terms of these changes”. Furthermore, dizziness is classified into four levels of complexity. This Dutch Dizziness Classification differentiates in the degree of daily dysfunctioning and psycho-social burden.
Conclusions: Both new definition and classification make it possible to evaluate the patient as a whole and include all relevant life domains. It gives the physician possibilities to tailor the therapy to the weight of the burden and with a multidisciplinary approach.
PPII:108 - The Impact of Postural Perceptual Dizziness: A Six-Week Follow-up Study Utilizing EQ-5D and Dizziness Handicap Inventory
Jorge Madrigal1, Ireri Espinoza1, Jajaira Mendivil2, Melissa Castillo-Bustamante3
1Centro de Vértigo y Mareo. Private Practice. Mexico
2Centro de Vértigo y Mareo. Private Practice. Colombia
3Clinica Universitaria Bolivariana/ Universidad Pontificia Bolivariana, Otolaryngology Department, Colombia
Purpose: This study delves into the impact of postural perceptual dizziness within an 8-patient case series, conducting a thorough 6-week follow-up using EQ-5D and Dizziness Handicap Inventory. By assessing patients' quality of life and functional impairment, our goal is to enhance understanding and inform targeted interventions for this specific population. This approach seeks to unravel the complexities of postural perceptual dizziness, contributing valuable insights for more effective and individualized treatment strategies.
Methods: From September to October 2023, a prospective case series was conducted at the Centro de Vértigo y Mareo and Clinica Universitaria Bolivariana, involving eight patients diagnosed with postural perceptual dizziness. Participants underwent vestibular rehabilitation and received medication. Over six weeks, the EQ-5D questionnaire measured health-related quality of life (QoL), and the Dizziness Handicap Inventory (DHI) quantified functional impairment. An ANOVA test was performed to evaluate DHI and EQ-5D changes throughout the 6-week follow-up. IRB approval was obtained at Universidad Pontificia Bolivariana
Results: The mean age was 47.6 (SD 17.4). Females were predominantly affected (62.5%). Initial EQ-5D scores were worse at the start of treatment in all patients. Throughout the follow-up, by the third week, most patients showed scores trending towards an improvement in QoL. At the 6-week follow-up, all patients demonstrated improvement in QoL scores. A descending trend was observed in all patients for Total DHI (p < 0.0001), Physical DHI (p < 0.0001), Emotional DHI (p = 0.01), and Functional DHI (p < 0.0001). All patients presented moderate or severe disability on all DHI scales.
Conclusions: Our study highlights promising outcomes in managing PPPD through a six-week intervention combining vestibular rehabilitation and medication. Significant improvements in quality of life and functional impairment underscore the effectiveness of this approach.
PPII:109 - TRANSDISCIPLINARY APPROACH TO VESTIBULAR REHABILITATION DECREASES COST AND IMPROVES RECOVERY TIME
Anna Mangano
1
1Baylor Scott and White Institute of Rehabilitation
Purpose: The purpose of this poster is to demonstrate the importance of a Transdisciplinar Model of Care in the management of vestibular disorders.
Methods: Retrospective data analysis of all patients referred to Baylor Scott and White Institute for Rehabilitation McKinney Lake Forest location with a diagnosis of either dizziness or BPPV. Subjects were split into two groups, those whose Physician was part of the Transdisciplinary team and those those Physician was not. Number of visits per each case were counted and coset per episode of care was estimated based on insurance reimbursement.
Results: An unpaired T test was performed on the grouped data. Overall cost savings when using a Transdisciplinary model: seen 4 fewer visits, saved approximately $1221. The cost savings per clinic was $324.
Conclusions: Creating a transdisciplinary team decreases the length of reovery and cost of recovery for patients with vestibular disorders. Members of this care team included: Physician, Physical Therapist, Speech Language Pathologist, Neuropsychologist, and Counslor.
PPII:110 - Unveiling the potential of Digit-in-Noise Test as a hearing screening tool for older adults with cognitive impairment
Patcharaorn Limkitisupasin
1
1Suranaree University of Technology, Institute of Medicine, Department of Otolaryngology, Thailand/ Chulalongkorn University, Faculty of Medicine, Department of Otolaryngology, Thailand
Purpose: Digit-in-Noise test (DIN) has gained recognition as a promising hearing screening instrument, particularly notable for its accuracy in assessing hearing ability, resilience to age-related effects, and minimal learning impact. DIN test excels in evaluating listening proficiency, especially in noisy backgrounds, which is commonly associated with age-related hearing loss and cognitive decline. Although endorsed by World Health Organization for general population screening, its validation within the cognitive impairment population remains lacking. This study addresses this gap by evaluating the DIN test’s diagnostic performance compared to pure-tone thresholds in older adults with cognitive impairment, marking the first validation of the DIN test in this specific population
Methods: Participants diagnosed with mild cognitive impairment (MCI) and dementia, were recruited from memory clinic. Each participant underwent an audiologic evaluation, including Hearing Handicap Inventory for Elderly (HHIE), Pure-tone audiometry, and Digit-in Noise Test. Additionally, Montreal Cognitive Assessment (MoCA), was administered.
Results: Among 36 adults (31 MCI and 5 dementia) with average age of 71.5 ± 4.9 years, a cut-off Speech Reception Threshold (SRT) of –5.5 yielded sensitivity of 0.8 for detecting 20 dB (mild hearing loss) and 1 for detecting 35 dB (moderate hearing loss). Specificity for detecting 20 dB and 35 dB was 0.7 and 0.41, respectively. ROC analysis indicated an AUC of 0.80 for mild hearing loss detection and 0.94 for moderate hearing loss detection. SRT showed a strong correlation with average PTA (R= 0.69) and weak correlations with HHIE score (R= 0.34).
Conclusions: Our findings underscore the potential of the DIN test, particularly in identifying moderate or disabling hearing loss among individuals with cognitive impairment. The strong correlation between SRT and PTA reinforces the clinical relevance of the DIN test as a reliable measure of hearing ability, even in the presence of cognitive impairment.
PPII:111 - Vestibular asymmetry and Jongkees´ formula: Do we interpret it correctly?
Maja Stříteská1, Erich Schneider2, David Wexler3
1Charles University Faculty of Medicine in Hradec Kralove
2Institute of Medical Technology Brandenburg University of Technology Cottbus - Senftenberg
3Stanford University School of Medicine, University of Southern Queensland
Purpose: The caloric test and the video head impulse test (vHIT) are the cornerstones of instrumental vestibular diagnostics. Both tests use Jongkees´ formula (JF) to calculate asymmetry, which can mislead clinicians if they interpret the results intuitively as an indication of how much the response of the (more) affected side is weaker than the contralateral side. We aimed to explain the meaning of the JF results and to discuss a choice of different asymmetry equations that allow a more intuitive assessment of the functional asymmetry between the two sides of the vestibular system.
Methods: We performed a mathematical analysis of JF to evaluate its non-linearity and underestimation compared to the linear result obtained by using the response of the stronger ear (SE) as a reference to which the weaker ear (WE) is related. Next, we performed a mathematical derivation to show what question JF actually answers.
Results: The JF always underestimates the paresis, reaching a maximum of 18% when the WE shows 41 % of the SE response. In addition, JF calculates the bilateral asymmetry from a “symmetry point,” splitting the difference between the two sides into two parts, with the average response in the middle.
Conclusions: Instead of indicating unilateral weakness as understood by clinicians, JF answers two other questions: “How much is the WE response below the average” and, at the same time, “How much is the SE response above the average”. Therefore, the non-linearity in JF is misleading because the actual degree of vestibular weakness in the caloric test, as well as the vHIT asymmetry, is greater than that calculated by JF.
PPII:112 - Vestibular clinic at Singapore General Hospital - our experience and patient outcomes
Chun Wai Yip1, Yew Meng Chan2
1National Neuroscience Institute , Singapore General Hospital, Department of Neurology , Singapore
2Singapore General Hospital, Department of Otolaryngology (ENT), Singapore
Purpose: The Vestibular clinic established at the Singapore General Hospital is a national/regional referral centre with comprehensive vestibular testing capabilities, and a combined oto-Neurology and ENT presence in the same centre.
We would like to present the Singapore vestibular clinic experience and the patient-reported outcomes at 3 month.
Methods: We retrospectively included 100 consecutive patients who attended over a 3 month period between Mar to May 2023 and the 3-month follow-up assessments. The data is retrieved from a registry database (with ethics approval).
Results: 1) The top 5 ICVD diagnoses were: Vestibular migraine 57%, Functional dizziness 13%, BPPV 10%, Menieres' disease 10%, unilateral vestibular loss 9%. 2) The referral sources are from : general ENT 41.1%, general neurology 20.7%, general practitioners 12.6%, others 25.6% (eg friend recommendation, internet search) 3) Patient demographics : a) Age : 20 to 88 years (mean 61 years, IQR : 51-73 years); b) Gender : Male : Female = 39% : 61%. 4) Investigations performed : CT brain/temporal bone 11%, MRI brain 58%; MRI inner ear 23%, vHIT 53% (2 or 6 canals), VEMPs 22%, Rotary chair 4%, Calorics 37%, Posturography 5%. 5) Patient-reported outcomes at 3 Months : resolved = 31.8% : improved significantly/mild symptoms = 38.6%
Conclusions: Our vestibular disorders case-mix mirrors those of other centres but in different order of frequency.
The majority of our patients are referred by other ENT/neurology specialists, due to the tertiary nature of our (hospital) set-up . Outreach to GPs/polyclinics ( through workshops and seminars) have also increased awareness of our service. About a quarter of the patients got to know our service from the internet/ word of mouth ecommendations etc.
We use a lot of imaging (including hydrops imaging) , vHIT and calorics testing , to exclude central causes of dizziness, and documenting peripheral vestibular deficits respectively. We are able to achieve relatively good 3-month patient reported outcomes with a combined 70.4% symptom resolution or improved with minimal symptoms.
PPII:113 - Vestibular deficit in presbycusis
Koray Koçoglu1, Grégory Gérenton1, Simona Caldani1, Sylvette R Wiener-Vacher1, Hung Thai-Van1
1Centre de Recherche et d’Innovation en Audiologie Humaine (CERIAH), Institut de l'audition, Institut Pasteur, Paris, France
Purpose: This study aimed to evaluate vestibular dysfunction in early presbycusis population.
Methods: This cohort study included 38 volunteers (14 males, 24 females, mean age ± SD, 70.3 ± 13.8 years) with early presbycusis (hearing thresholds between 35-106 dB). The vestibular evaluation included a caloric test (CT), air-conducted cervical and ocular vestibular-evoked myogenic potentials (VEMPs), rotatory chair (RC), and video Head Impulse Test (vHIT). The Dizziness Handicap Inventory (DHI) evaluated the impact of vestibular status on global balance. Correlations were studied between audiometric thresholds (PTA) and vestibular responses.
Results: The abnormal responses of subjects in vHIT were 28.9% of the posterior, 10.5% of the lateral, and 7.9% of the anterior semicircular canals (SSCs). For vHIT, the mean gain values of lateral, anterior, and posterior SSCs were 0.96±0.11, 0.94±0.11, and 0.78±0.21, respectively. Response to RC was present at all velocities (25, 35, and 55°/sec) and all subjects (mean gain between 30-35% and phases between 12-17°/sec). For CT, no deficit was observed (unilateral weakness was 5.06±5.32% and directional preponderance was 5.05%±5.16%). Otolith responses to oVEMP were absent in 57.9% of the cases and to cVEMP in 23.7%. For cVEMPs, the mean P and N latency were 13.10 ± 1.33 ms, 19.92 ± 2.13 ms, respectively, and the amplitude ratio was 11.21%±8.14%. For oVEMPs, the mean N and P latency were 10.01 ± 0.84 ms, 13.92 ± 2.19 ms, respectively, and the amplitude ratio was 4.16% ± 3.01%.
Conclusions: This study shows that some presbycusis can be associated with vestibular dysfunction particularly posterior SSCs at high head rotation velocity (28.9% of the cases) and otolith organs (58.9% utricular and 23.9% saccular dysfunction). These results suggest that the pathological mechanism for some early presbycusis may be at the end organ level.
Selected references
PPII:114 - Vestibular function in patients diagnosed with obstructive sleep apnea
Emil Krogsgaard Nielsen1, Peter Brandt Sloth1, Dan Dupont Hougaard2
1Aalborg University Hospital, Department of Clinical Medicine, Aalborg, Denmark
2Aalborg University Hospital, Balance & Dizziness Centre, Department of Otorhinolaryngology, Head & Neck Surgery and Audiology, Aalborg, Denmark
Purpose: This study aimed to determine the prevalence of vestibular hypofunction in a cohort of Danish adults diagnosed with obstructive sleep apnea (OSA). Secondary objectives were to determine, if there was any correlation between vestibular hypofunction and the degree of sleep apnea and/or the total- and subcategory Dizziness Handicap Inventory (DHI) questionnaire scores.
Methods: A cross-sectional prospective cohort design in which 175 adult subjects diagnosed with either probable, mild, moderate, or severe OSA (based on their initial apnea-hypopnea-index (AHI) score) were recruited from the Department of Otorhinolaryngology, Head & Neck Surgery at Aalborg University Hospital. Subjects underwent complete video head impulse testing (vHIT) and a self-reported fulfilment of the 25-item DHI questionnaire. A standardized approach was applied for the interpretation and classification of the vHIT results.
Results: Of the 191 patients included, 175 met the eligibility criteria. Age range: 25-82. Gender distribution: 66.3% males and 33.7% females. Mean AHI score: 36.9. Mean DHI score: 9.7. Of the 1050 semicircular canals tested, 941 were included in the final data analysis. Twelve subjects (6.9%) had pathological vHIT results. 23 (13.1%) and 43 (24.6%) subjects had isolated pathological mean gain values or saccades, respectively. No significant differences in AHI score (p=0.26) or within AHI groups (p=0.45) were found between subjects having normal and pathological vHIT. Consistently, no significant differences in total DHI score (p=0.14) or within DHI subcategories (p=0.21) were found between subjects having normal and pathological vHIT.
Conclusions: Twelve subjects (6.9%) in a population of adult OSA patients had vestibular hypofunction. No correlation between the prevalence of vestibular hypofunction and the degree of OSA was found. Consistently, no correlation to the total- or subcategory mean DHI scores was found.
PPII:115 - Vestibular Signs and Symptoms in Parkinson’s disease: a systematic review
Francisco Martins1, Beatriz Santos2, Raquel Bouça-Machado3, Claudia Costa4, Joaquim J Ferreira5
1CNS | Campus Neurológico, Torres Vedras, Portugal; Polytechnic Institute of Setubal, Setubal, Portugal
2CNS | Campus Neurológico, Torres Vedras, Portugal
3CNS | Campus Neurológico, Torres Vedras, Portugal; Polytechnic Institute of Setubal, Physiotherapy, Portugal; Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Po
4Faculty of Medicine, University of Lisbon, Lisbon, Portugal; Escola Superior de Saúde Atlantica, Barcarena, Portugal
5CNS | Campus Neurológico, Torres Vedras, Portugal; Laboratory of Clinical Pharmacology and Therapeutics, Faculdade de Medicina de Lisboa Universidade de Lisboa Portugal; Instituto de Medicina Molecula
Purpose: There is a growing interest in exploring the link between Parkinson’s disease (PD) neuropathology and the vestibular system. Nonetheless, vestibular and oculomotor impairments remain underreported and underestimated. This study aims to (1) identify and list the vestibular signs and symptoms reported in PD patients and (2) summarize and critically evaluate the measurement tools used to assess them.
Methods: This systematic review was conducted using MEDLINE, Web of Science, Scopus, and PEDro databases from their inception to June 2023. All experimental and observational studies in PD patients that reported vestibular signs or symptoms and assess vestibular system were included.
Results: There were 134 symptoms reported in this review, divided into 4 groups according to the Barany consensus: dizziness (n=93, 69.4%); vertigo (n=15, 11,2%); postural symptoms (n=13, 9.7%) and vestibulo-visual symptoms (n=10, 7.5%). An additional group was created for an association between them (n=3, 2.2%).
A total of 298 signs were mentioned in the articles. Ten groups were created to allocate them: nystagmus (n=40, 13.4%); postural control impairments (n=92, 30.9%); central oculomotor abnormalities (n=50, 16.8%); vestibular evoked myogenic potential impairments (n=39, 13.1%); global peripheral vestibular function impairment (n=23, 7.7%); subjective vertical perception impairments (n=15, 5%); impaired vestibulo-ocular reflex (VOR) (n=14, 4.7%); impaired VOR suppression (n=11, 3.7%); impaired vestibulo-spinal reflexe (n=1, 0.3%) and non-specific signs (n=13, 4.4%).
Nevertheless, the vestibular etiology of some signs and symptoms were not fully elucidated.
Conclusions: Vestibular signs and symptoms were found in people with PD. This highlights the importance of considering and assessing them during the rehabilitation process.
