Exhibition and poster viewing (poster session 1)
PP1-1 - 3D Visualization and Position of Human Inner Ear Graviceptors A Synchrotron Imaging Study
1. Anatomy and Morphology
Sumit Agrawal1
Hanif M. Ladak2, Helge Rask-Andersen3,
Hao Li
3
1 Western University, Department of Otolaryngology-Head and Neck Surgery, Canada
2 Western University, Department of Otolaryngology-Head and Neck Surgery, Department of Medical Biophysics and Department of Electrical and Computer Engineering, Canada
3 Uppsala University Hospital, Department of Surgical Sciences, Head and Neck Surgery Section of Otolaryngology, Department of Otolaryngology, Sweden
Purpose: Receptors located in the inner ear, muscles tendons and joints provide sensory information of body position, static equilibrium and gravitational forces. The saccule and utricle maculae in the labyrinth is a body “gyroscope” that delivers information to the brain of head orientation, gravity and linear acceleration. Their exact position and shape of the sensory tissues within the human skull are still somewhat poorly defined.
Methods: We used synchrotron-phase contrast imaging (SR-PCI) to study the 3D micro-anatomy and position of the gravireceptors in the human skull. This was accomplished by reconstructing human soft inner ear tissues including the sensorineural epithelial outline with juxtaposing CT skull images.
Results: The geometric position and outline of the maculae were also assessed relative to the location of the round and oval windows, stapes foot plate, cochlear lateral wall tissue and spiral lamina. Besides this information the 3D outline of the membranous endolymph duct system could be defined.
Conclusions: The exact position and shape of the inner ear graviceptors were mapped in the human skull using synchrotron-phase contrast imaging.
PP1-2 - A multifaceted tailored randomised-controlled trial to reduce the burden of dizziness in middle aged and older people
1. Anatomy and Morphology
J Menant
1
J Close2, A Migliaccio1, N Titov3, K Delbaere1, D Sturnieks1, C Mc Veigh2, S Lord1
1 NeuRA, UNSW, Sydney, NSW, 2031, Australia
2 NeuRA, UNSW, Sydney, NSW, 2031, Australia; Prince of Wales Clinical School, UNSW, Sydney, NSW, 2031, Australia
3 Department of Psychology, Macquarie University, Sydney, NSW, 2109, Australia
Purpose: Dizziness is common among middle-aged and older people. Its multifactorial etiology makes it difficult to investigate and if untreated, dizziness can lead to reduced quality of life, functional disability, depression, restricted participation in social activities and falls. Only a few multidisciplinary interventions of dizziness have been conducted to date, all of a pilot nature and none tailoring the intervention to the specific causes of dizziness.
The study aimed to test the hypothesis that a multidisciplinary dizziness assessment followed by a tailored multifaceted intervention would reduce dizziness handicap and self-reported dizziness, and enhance balance and gait in people aged 50 years and over with dizziness.
Methods: 305 community-dwelling people (mean (SD) age 68 (8) years, 62% women) who reported dizziness in the 12months prior and were not receiving treatment for it, completed the dizziness handicap inventory (DHI) and questionnaires regarding medical history, anxiety and depression. They also underwent assessments of vestibular function, sensorimotor function, balance, stepping and gait. Our multidisciplinary team of scientists and clinicians held case conferences fortnightly to discuss and recommend appropriate therapy(ies) for each participant, based on their baseline assessments. Participants were then randomised to intervention or control groups, and based on their test performances, intervention participants were allocated to one or more interventions: vestibular rehabilitation, cognitive behavioural therapy, medical/medication management by a general practitioner or at a falls clinic and strength and balance exercises using the Otago exercise program. Primary outcome measures comprised the DHI, frequency of dizziness episodes recorded with monthly calendars over the six-month follow-up, choice stepping reaction time and gait variability.
Results: At trial completion, the DHI scores in the intervention group (pre and post mean (SD): 25.9 (19.2) and 20.4 (17.7), respectively) were significantly reduced when compared to the control group (pre and post mean (SD): 23.0 (15.8) and 21.8 (16.4)), when controlling for baseline scores (mean (95% CI) difference between groups (baseline adjusted): -3.7 (-6.2 to -1.2); p=0.003).There were no other significant between-group differences in the primary outcomes. However, there were intervention-specific improvements in those allocated to the four intervention types.
Conclusions: The findings indicate that a multifactorial tailored approach for treating dizziness is effective in reducing dizziness handicap in community-living people aged 50 years and older. Individualised multifaceted evidence-based therapies should be implemented to improve the quality of life of middle-aged and older people with dizziness.
PP1-3 - Developing a Model for Quantification of Heat Transfer to the Vestibular System
1. Anatomy and Morphology
Charles Anzalone
1
Yening Feng1, Matthew Carlson1, Devin McCaslin2, Gayla Poling2, David Kallmes3, John Lane3, Shuai Leng3, Kent Carlson4, M. Dan Dragomir-Daescu4
1 Department of Otorhinolaryngology, Mayo Clinic, Rochester, MN
2 Department of Audiology, Mayo Clinic, Rochester, MN
3 Department of Radiology, Mayo Clinic, Rochester, MN
4 Department of Engineering, Mayo Clinic, Rochester, MN
Purpose: Caloric modulation of the vestibular system is an established technique to determine inner ear function. We aim to develop a cadaveric model to determine the role specific anatomic variables play in temperature change at the level of the lateral semicircular canal (LSC)
Methods: Two fresh frozen cadaveric heads were evaluated using a 192 slice computed tomography (CT) scanner to evaluate for standardized anatomy as well as tissue thickness and density. A continuous caloric irrigation system was placed at either the level of the external auditory canal or direct irrigation into the middle ear space; thermocoupling electrodes at the external auditory canal (EAC), middle ear, and LSC provided real time temperature monitoring.
Results: Radiographic analysis of each cadaveric model was performed to quantify anatomic variables: surface area and volume of the EAC, surface area of the tympanic membrane, volume and surface area of the middle ear space, LSC bony thickness, volume, surface area and distance to the tympanic membrane. Specific temperature coefficients were determined based off of contributions of air, bone, and soft tissue densities. Temperature transfer models were constructed from these variables.
Conclusions: Determining the variables affecting the delivery of heat to the LSC are paramount to determining the degree of vestibular stimulation from a given input temperature. Our model provides a reliable method of quantifying temperature transfer across the external, middle and inner ear anatomy. Further study is required to correlate these data to the general population.
PP1-4 - Distribution of extracellular matrix in vestibular nuclei of developing mouse brain stem
1. Anatomy and Morphology
András Birinyi
1
Ildikó Wéber1, Klara Matesz1
1 Department of Anatomy, Histology and Embryology, Debrecen, Hungary
Purpose: The molecular and structural composition of the extracellular matrix (ECM) in the central nervous system undergoes profound transformation during embryonic and early postnatal development. The aim of this study was to detect the changes of staining pattern of different ECM molecules in the developing mouse brainstem.
Methods: We used using histochemical (Wisteria floribunda agglutinin (WFA), hyaluronic acid probe (HA)) and immunohistochemical (aggrecan, neurocan, versican (GAG beta), TN-R and HAPLN1) methods.
Results: We found that HA, neurocan and versican reactions showed diffuse neuropil staining at very early embryonic stage (E13.5), but perineuronal net (PNN) composed of these molecules were observed only postnatally (P7). We could not find any aggrecan, WFA or HAPLN1 staining before birth. Postnatally WFA and aggrecan established PNN in the reticular formation and in the vestibular and other brainstem nuclei. HAPLN1 were restricted to the neuropil of some brainstem nuclei, in contrast to HA, neurocan and TN-R which were found throughout the brainstem.
Conclusions: Our results show that at early stages of development only a diffuse staining of ECM molecules is present in the neuropil of the brainstem and the formation of a definitive PNN is recognizable postnatally. We found well developed PNNs in the vestibular nuclei of the brainstem in two weeks old animals. It is expected that the pattern of ECM expression appears to be related to the functional maturation of brainstem neural circuits, which is also evident in other developmental processes such as neurogenesis, synaptogenesis or synaptic plasticity.
Supported by OTKA K 115471, and MTA TKI 355.
PP1-5 - Ion Transport Proteins and Claudin 11 Barrier in the Lateral Wall of the Human Cochlea
1. Anatomy and Morphology
Wei Liu
1
Rudolf Glueckert2, Annelies Schrott-Fischer2, Heval Benav3, Charlotta Kämpfe1, Göran Laurell1, Helge Rask-Andersen1
1 Uppsala university, ENT dept., Uppsala, Sweden
2 University of Innsbruck, ENT dept., Innsbruck, Austria
3 MED-EL GmbH, Fuerstenweg 77a, A- 6020 Innsbruck, Austria
Purpose: The cochlea produces an electric field potential essential for hair cell transduction and hearing. This biological “battery” is situated in the lateral wall of the cochlea and contains highly organized molecular/cellular arrangement that secretes and recycles K+ ions. Its functioning depends on ion-transporting machinery and junctional proteins that guarantee a unidirectional delivery of K+ and restrict the para-cellular escape of the ion. Claudin 11 protein has been found to be one of the major constituents at tight junction that maintains ion gradients (Gow et al., 2004; Kitajirietal., 2004). We are the first to elucidate the human Claudin 11 framework and the associated ion transporters (channels/pumps/carriers) using super-resolution structured illumination microscopy (SR-SIM).
Methods: Archived human cochleae obtained during meningioma surgery were used for SR-SIM, together with confocal laser scanning microscopy and transmission electron microscopy after ethical permission as well as patients’ consent.
Results: Claudin 11-expressing cells formed parallel tight junction lamellae that insulated the epithelial layers of the stria vascularis and extended to the suprastrial region. Intercellular gap junctions were found between the barrier cells and fibrocytes.
Conclusions: EM, CLSM and SR-SIM revealed exclusive cell specialization in the various subdomains of the lateral wall of the human cochlea. The Claudin 11-expressing cells exhibited both conductor and isolator characteristics, and these microporous separators may selectively mediate the movement of charged units (mainly K+) to the intrastrial space in a manner that is analogous to a conventional electrochemical “battery.” The function and relevance of this “battery” for the development of inner ear diseases are discussed.
PP1-6 - Is there a Neuroimmunoaxis in the Human Inner Ear - Role in Disease and Repair?
1. Anatomy and Morphology
Wei Liu
1
Helge Rask-Andersen1
1 Uppsala university, surgical sciences department
Purpose: The human inner ear is segregated by a blood/labyrinth barrier but contains resident macrophages/microglia (CD163, IBA1-, and CD68-positive cells) within almost all the tissues including neurons and organ of Corti. In the lateral wall of the cochlea, these cells lie close to blood vessels as perivascular macrophages. Macrophages are also shown to be recruited from blood-borne monocytes to damaged and dying hair cells induced by noise, ototoxic drugs, aging and diphtheria toxin-induced hair cell degeneration. Precise monitoring may be crucial to avoid self-targeting. Macrophage biology has recently shown that populations of resident tissue macrophages may be fundamentally different from circulating macrophages. Macrophage migration inhibitory factor protein (MIF) signaling is a potential route to develop new therapeutic strategies to repair adult spiral ganglion neurons, hair cell synapses and even form new neurons from stem cells.
Methods: Human cochleae were removed during surgery for treating petro-clival meningioma compressing the brain stem, after ethical consent. Molecular and cellular characterization using immunohistochemistry with antibodies against IBA1, TUJ1, CX3CL1 and type IV collagen, and super-resolution structured illumination microscopy (SR-SIM) were made together with transmission electron microscopy.
Results: High resolution microscopy disclosed remarkable phenotypic variants of IBA1 cells closely associated with the spiral ganglion cells. Monitoring cells adhered to neurons with “synapse-like” specializations and protrusions. Active macrophages migrated occasionally nearby damaged hair cells.
Conclusions: In the human cochlea, the labyrinthine nerves are under the influence of a neurotrophic cytokine/chemokine cross-talk with the immune system. The interaction has possible roles in human inner ear disease, sensorineural injury, and repair processes.
PP1-7 - Microcomputed Tomography Analysis of the the Fundus of the Human Internal Acoustic Canal
1. Anatomy and Morphology
Nadine Schart-Morén
1
Sune Larsson2, Hao Li1, Helge Rask-Andersen1
1 Department of Surgical Sciences, Otorhinolaryngology, Head and Neck Surgery, Uppsala University, Uppsala, Sweden
2 Department of Surgical Sciences, Orthopedics, Uppsala University, Uppsala, Sweden.
Purpose: The purpose of the study was to better understand and visualize tha anatomy of the human fundus with microcomputed tomography. Identification of the cochleovestibular nerve in the internal acoustic canal is crucial before cochlear implantation and other surgical interventions, such as tumor removal, vestibular nerve section, and decompression procedures. They all require a thorough knowledge of the gross and topographical anatomy in humans.
Methods: Using microcomputed tomography, we analyzed the fundus bone channels in an archival collection of 113 macerated human temporal bones and 325 plastic inner molds. Data were subsequently processed by volume-rendering software using a bony tissue algorithm. Three-dimensional reconstructions were made, and through orthogonal sections, the topographic anatomy was established.
Results: The technique provided additional information regarding the anatomy of the nerve foramina/channels of the human fundus region, including variations and destinations. Channel anastomosis were found beyond the level of the fundus. A foramen of the transverse crest was identified.
Conclusions: Three-dimensional reconstructions and cropping outlined the bone canals and demonstrated the highly variable VIIIth nerve anatomy at the fundus of the human inner acoustic canal. Myriad channel interconnections suggested an intricate system of neural interactive pathways in humans. Particularly striking was the variable anatomy of the saccule nerve channels. The results may assist in the preoperative interpretation of the VIIIth nerve anatomy.
PP1-8 - A new procedure of labyrinthectomy in mice by means of transtympanic injection of p-arsanilic acid
2. Animal Models and Molecular Approach
Kazuki Nakahara
1
Taeko Ito2, Kouko Tatsumi1, Tadashi Kitahara2, Akio Wanaka1
1 Nara Medical University, Department of Anatomy and Neuroscience, Japan
2 Nara Medical University, Department of Otolaryngology-Head and Neck Surgery, Japan
Purpose: Unilateral labyrinthectomy (UL) is usually adapted to make an animal model of vestibular dysfunction. However, there are few papers about UL in mice. For further understanding of vestibular compensation, a new method of UL in mice is required. In the present study, we devised a new accessible and reliable method to damage mice inner ear.
Methods: We used 8 weeks old male C57BL/6N mice. A retroauricular incision was made to expose the external ear canal. It was opened just anterior to the exit point of facial nerve and the tympanic membrane was perforated caudally to handle of malleus. After paracentesis, 50 µl of 0.4M p-arsanilic acid sodium salt solution was instilled into the tympanic cavity and after 5 min, the solution was aspirated. As behavior markers, we recorded head deviation and spontaneous nystagmus using a digital camera. Head deviation was measured once a day, defined as the angle between the horizontal plane and a line passing through the center of the animal’s head in the coronal plane. To understand the neurological activities in vestibular nucleus (VN), we counted immunoreactive cells of immediately early genes (IEGs): c-fos, Arc, and Zif268.
Results: The angle of head deviation became the least at 48 hrs and gradually recovered by 168 hrs after UL. The spontaneous nystagmus appeared at 24 hrs and disappeared by 48 hrs after UL. IEGs-immunoreactivities in VN were higher in the injured side than the intact side.
Conclusions: The present UL procedure is simple and reliable for making a mice model of vestibular dysfunction.
PP1-9 - Altered circadian locomotor activity after acute otovestibular failure in rodents.
2. Animal Models and Molecular Approach
Vincent Van Rompaey
1
Stephan Missault1, Krystyna Szewczyk1, Paul Van de Heyning1, Peter De Deyn2, Debby Van Dam2
1 University of Antwerp, Faculty of Medicine and Health Sciences, Dept. Translational Neurosciences, Belgium
2 University of Antwerp, Laboratory of Neurochemistry and Behaviour, Institute Born-Bunge, Faculty of Pharmaceutical, Biomedical and Veterinary Sciences, Belgium
Purpose: Similar to Alzheimer’s disease, diurnal rhythm disturbances and cognitive dysfunction have been observed in rodent models of bilateral vestibulopathy (BV). Sleep and circadian disruption can impair hippocampal neurogenesis and subsequently impair hippocampus-dependent learning and memory. Recent insights have explored the connection between the vestibular system and hypothalamic regulation of circadian rhythms.
The aim of this study was to evaluate circadian patterns of locomotor activity before and after acute otovestibular failure in mice.
Methods: We evaluated adult 129S1/SvImJ mice, purchased from Charles River - Jackson Laboratories (JAX), 1 week before and 1 week after allylnitrile exposure (p.o. in 6 ml/kg of corn oil). Vestibular function was evaluated with the validated score reported by Jordi Llorens. Cage activity was evaluated continuously over a period of 47 hours, including a 12-hour dark phase (active) and a 12-hour light phase (less active). Ambulatory movements (e.g. walking through cage) included multiple infrared beams crossed sequentially. Fine movements (e.g. grooming) included one infrared beam disrupted multiple times. Statistical analysis was performed using a mixed model with random and fixed effects.
Results: Allylnitrile exposure resulted in acute-onset and permanent vestibular failure and profound sensorineural hearing loss. A statistically significant interaction was observed on ambulatory (p<0.05) and fine movements (p<0.0001) when comparing measurements before versus after allylnitrile exposure and comparing with the control group.
Conclusions: Our findings support the hypothesis that the vestibular system has a short-term influence on daily rhythm homeostasis in rodents. This circadian rhythm disturbance might play a role in decreased adult hippocampal neurogenesis and spatial cognitive decline.
PP1-10 - Effect of thioperamide on vestibular compensation in rats with immunohistochemistry
2. Animal Models and Molecular Approach
Kazunori Matsuda
1
Tadashi Kitahara2, Taeko Ito2, Munehisa Fukushima3, Go Sato1, Noriaki Takeda1
1 Department of Otolaryngology, University of Tokushima School of Medicine,Japan
2 Department of Otolaryngology- Head and Neck Surgery, Nara Medical University,Japan
3 Department of Otolaryngology and Head and Neck Surgery, Osaka University Graduate School of Medicine, Japan
Purpose: Unilateral labyrinthectomy (UL) causes ocular and postural asymmetries, which disappear over time in the processes of equilibrium recovery known as vestibular compensation.
Vestibular compensation consists of two stages: the inhibition of the contralesional medial vestibular nucleus (contra-MVe) activities at the acute stage after unilateral labyrinthectomy (UL) and the recovery and maintenance of the ipsilesional MVe (ipsi-MVe) spontaneous activities at the chronic stage after UL.
Methods: In rats, the inhibitory N-methyl-D-aspartate (NMDA) receptor systems related to central vestibular system may play an important role for central processes of the vestibular compensation. Therefore, the expression of MK801(a specific antagonist of NMDA receptors )-induced Fos-like immunoreactive (-LIR) neurons in the contra-MVe after UL demonstrated the time course of vestibular compensation.
We evaluated the progression of vestibular compensation at two stages. The acute stage of vestibular compensation was evalutated with changes of spontaneous nystagmus frequency, the chronic stage of vestibular compensation was evalutated with temporal changes of MK801-induced Fos-LIR neurons in the contra-MVe after UL.
There have been no study directly demonstrating the influence of thioperamide, a pure antagonist of the H3 receptor, on vestibular compensation with immunohistochemistry.
Results: Neither SN frequency nor its rate of compensation were significantly different between Thioperamide-treated group and the control untreated group. In contrast, Thioperamide-treated group significantly decreased earlier the temporal changes of MK801-induced Fos-LIR neurons in the contra-MVe after UL compared with the control group.
Conclusions: In conclusion, Thioperamide improve the chronic stage of vestibular compensation in rats, not the acute stage.
PP1-11 - Evaluating an kinase inhibitor library for effects on hair cells using the zebrafish lateral line
2. Animal Models and Molecular Approach
Yoshinobu Hirose
1
Yousuke Takemoto1, Kazuma Sugahara1, Makoto Hashimoto1, Hiroshi Yamashita1
1 Department of Otolaryngology, Yamaguchi University Graduate School of Medicine, Japan
Purpose: Zebrafish lateral line hair cells are physiologically and morphologically similar to inner ear hair cells. As the zebrafish lateral line is located on the body surface, damage to the hair cells can be rapidly assessed. Therefore, the zebrafish lateral line is an effective system for the evaluation of drugs that damage or protect hair cells. In this study, we examined the role of kinase in hair cells. A kinase phosphorylates a protein, have an important role for hair cell alive or death. We have screened a library of 18 kinase inhibitor-drugs that protected or damaged hair cells of the zebrafish lateral line.
Methods: 5 days post-fertilization zebrafish were used in this study. Larvae were exposed to kinase inhibitor (0.1-10 ug/ml) with or without neomycin (100 uM) to investigate hair cell protection and toxicity . Anti-parvalbumin was used as a primary antibody, hair cells were immunostained. Hair cells from the SO1, SO2, O1, and OC1 neuromasts were counted with a fluorescent microscope.
Results: One kinase inhibitor drug show toxity in hair cells. On the other hand, the screen successfully identified four protecting drugs against neomycin.
Conclusions: We examined the relevant of kinase and hair-cell death using the larvae of a zebrafish. Our date suggested that kinase were work as toxic and protective effect in hair cells.
PP1-12 - Extracellular matrix in vestibular compensation
2. Animal Models and Molecular Approach
Botond Gaál
1
Ágnes Magyar2, Klára Matesz1, Éva Rácz1
1 University of Debrecen, Dept. of Anatomy
2 University of Debrecen, Dept. of Pediatric Surgery
Purpose: Impaired balance function evokes postural, oculomotor and autonomic deficits, which symptoms partly restore by vestibular compensation. The role of extracellular matrix (ECM) has been long suggested in such plastic modifications of a neural network. Our laboratory investigates the ECM environment in the brainstem vestibular nuclei (VN) of rats, mice and frogs both in physiological conditions, and during compensation after unilateral labyrinth lesion. We perform the damage of balance receptors mechanically, by microsurgical exposure of the labyrinth.
Methods: ECM in the mammalian CNS is composed of hyaluronan (HA), chondroitin sulfate proteoglycans (CSPG) and glycoproteins. This ternary complex accumulates as perineuronal net (PNN) surrounding perikaryons and neuronal processes, or is distributed diffusely. The PNNs stabilize synaptic contacts on the perikaryon and neuronal processes, but also influences restoration capacity of the vestibular system. In contrast with mammals, our results confirmed a HA based ECM in the amphibian VN.
Results: In frogs transection and reunion of the vestibular nerve was followed by an in-growth of nerves into VN and re-establishment of synaptic contacts, parallel with restoration of vestibular functions. In normal rats and mice unilateral damage of the inner ear initiated a radical but dynamic alteration of PNNs in the VN, which is temporally parallel with functional recovery, although no evidence proves considerable axonal re-growth.
Conclusions: These experiences suggest that a HA-rich but CSPG-free perineuronal environment facilitates a high degree of plasticity and regenerative potential in frogs, whereas in rodents the strong presence of CSPGs presumably is against plastic modifications of the vestibular network.
PP1-13 - Locomotor hyperactivity in bilateral vestibulopathic rats: a consequence of spatial disorientation?
2. Animal Models and Molecular Approach
Andreas Zwergal
1
Eva Eilles2, Lisa Günther2, Roswitha Beck2, Magdalena Lindner2, Marianne Dieterich1, Thomas Brandt3
1 Ludwig-Maximilians-University Munich, Department of Neurology, German Center for Vertigo and Balance Disorders (DSGZ)
2 Ludwig-Maximilians-University Munich, German Center for Vertigo and Balance Disorders (DSGZ)
3 Ludwig-Maximilians-University Munich, Clinical Neurosciences, German Center for Vertigo and Balance Disorders (DSGZ)
Purpose: Comparative investigation of the locomotor behaviour in open and restricted space after bilateral labyrinthectomy in the rat.
Methods: Ten Sprague-Dawley rats underwent a bilateral labyrinthectomy (BL) by transtympanic injection of bupivacaine and arsenilate, 10 rats received a bilateral middle-ear injection of saline (sham) as a control group. Behavioural testing was performed 1 day before and at days 1, 2, 3, 7, 15, 30 and 60 after BL/sham injection as follows: 1) quantitative analysis of locomotor and spatial exploration behaviour in a square open field by the Noldus EthoVision System; 2) quantitative analysis of locomotion pattern in a straight corridor by the Noldus CatWalk System.
Results: In the open field, mean locomotor velocity was significantly higher in the BL than in the sham group until day 60. This was mostly due to different movement strategies in open space: rats of the sham group showed a strategically distributed exploration pattern with a preferred movement along the lateral edges at all time points. In contrast, rats of the BL group presented with a omnidirectional exploration strategy and stayed in the central parts of the open field significantly longer. A completely different locomotor behaviour was seen in restricted space: mean locomotor velocity during CatWalk measurement was lower at the initial time points and adapted consecutively between groups after day 15 post BL/sham injection.
Conclusions: Locomotor hyperactivity following a bilateral vestibular lesion seems to be a consequence of disorientation in open space. Locomotor velocity in restricted space adjusts completely to the level of controls indicating central compensation mechanisms.
PP1-14 - Macrophages in the Human Endolymphatic Sac - Molecular Expression and Interaction
2. Animal Models and Molecular Approach
Charlotta Kämpfe Nordström
1
Niklas Danckwardt-Lillieström1, Wei Liu1, Helge Rask-Andersen1
1 Uppsala University Hospital, Department of Surgical Sciences, Uppsala
Purpose: Several otologic disorders are thought to have an immunologic component. The endolymphatic sac (ES) is endowed with a multitude of white blood cells and may serve as an immunologic defense organ for the inner ear. Recently, the human ES, as well as the rest of the inner ear, were found to contain resident macrophages. To gain more information about their roles, we examined these cells using super resolution structured fluorescence microscopy (SR-SIM).
Methods: Human vestibular aqueducts were removed during trans-labyrinthine surgery for removal of acoustic neuroma. Tissues were placed in fixative, decalcified, and rapidly frozen and cryostat sectioned. Antibodies against IBA-1, fractalkine (CX3CL1) and the major histocompatibility type II (MHCII) were used.
Results: A larger number of IBA1-positive cells than expected were found to reside in the ES populating both the surrounding connective tissue and the epithelial lining. Several epithelial cells expressed IBA1 as well as the major histocompatibility complex II (MHCII). Evidence of macrophage diapedesis into the ES lumen was obtained. The chemokine CX3CL1 was richly expressed in the ES.
Conclusions: Macrophages constitute a large, interactive population of locomotive sub-epithelial, intra-luminal and fixed epithelial cells in the human ES. Molecular expression includes that of antigen-presenting cells important for initiating immune responses.
PP1-15 - Neural Correlates of Galvanic Vestibular Stimulation in the Alert and Behaving Macaque
2. Animal Models and Molecular Approach
Kathleen Cullen
1
Annie Kwan2, Jean-Sébastien Blouin3, Patrick Forbes4
1 Johns Hopkins University, Baltimore, USA
2 McGill University, Montreal, Canada
3 University of British Columbia, Vancouver, Canada
4 Erasmus Medical Centre, Rotterdam, the Netherlands
Purpose: The vestibular influence on motor and perceptual responses can be manipulated in isolation by delivering electrical currents over the mastoid processes. This galvanic vestibular stimulation (GVS) evokes stereotypical ocular and postural responses as well as virtual sensations of motion that have been well described in humans. Exactly how this non-invasive tool activates the vestibular system, however, remains an open question.
Methods: To link neuronal and behavioural responses, we recorded eye movements and individual vestibular afferent activity while applying transmastoid GVS in alert macaques.
Results: We found that GVS predominately evoked torsional eye movements, similar to those reported in humans. Our single unit recordings revealed that canal and otolith afferents were similarly activated by GVS. Notably, afferents from both types of sensors displayed high-pass tuning, with irregular afferents showing greater response modulation. This differs markedly from their response to natural motion and overturns previous expectations that afferent response dynamics to GVS are invariant across stimulation frequency.
Conclusions: Taken together, these results reveal the neural correlates underlying GVS-evoked perceptual, ocular and postural responses – a fundamental step into understanding the representation and use of such information in the brain that is critical to advance the applicability of GVS for biomedical uses in humans.
PP1-16 - Photobiomodulation for peripheral vestibular dysfunction induced by aminoglycoside in animal model
2. Animal Models and Molecular Approach
Jung Hyun Ahn
1
Jae Yun Jung1, Ji Eun Choi1, Min Young Lee1
1 Department of Otorhinolaryngology, Hean and Neck Surgery, Dankook University Hospital
Purpose: Vertigo is related to the dysfunction of peripheral vestibular system and no specific medical treatment is available to cure the symptom. Gentamicin is known vestibular toxic agent, various degree of balance problem is observed after exposure to this pharmacologic agent. Photobiomodulation using low level laser is widely adopted in medical field, and due to its ability to reach deeply locating organs inner ear is one of the candidate target. But not much studies have shown the effect of photobiomodulation on balance function.
Methods: We used rat model to resemble the human vestibulopathy condition using Gentamicin and evaluated the effect of photobiomodulation on this vestibular toxicity. Both functional and histologic evaluation were aimed to assess the cupula of lateral semicircular canal. Slow Harmonic Acceleration (SHA) rotating chair testing was used for functional evaluation and both qualitative and quantitative epifluorescence analysis of cupula histology was performed. Animals were divided into laser group and Gentamicin only group. Laser was applied in unilateral ear, and function and histology was evaluated in both ear.
Results: After Gentamicin treatment, decrease of function of both ear was observed, showing low gain and no asymmetry. With laser treatment to unilateral ear, this reduction was minimized showing increased gain in laser treated ear and showing asymmetry of right and left ear function. Histological results corresponded to the functional results showing increased density of hair cell and epifluorescence intensity in laser applied cupula.
Conclusions: Promising outcome was observed showing increased vestibular function after photobiomodulation and this could be alternative approach for vestibulopathy.
PP1-17 - Tissue optical clearing of the mouse temporal bone for downstream applications
2. Animal Models and Molecular Approach
Tomoko Makishima
1
Rebecca Cook1, Lorenzo Ochoa2, Gracie Vargas2
1 University of Texas Medical Branch, Department of Otolaryngology, U.S.A.
2 University of Texas Medical Branch, Department of Neuroscience, Cell Biology and Anatomy, U.S.A.
Purpose: The mouse inner ear histological analysis is challenging due to its membranous structures encapsulated within a small, hard, boney shell, the temporal bone. Tissue optical clearing techniques enable whole organs to be studied without tedious fine dissection. While different organs have been successfully cleared, the temporal bone is one of the more difficult organs to manipulate. Tissue optical clearing needs to be combined with suitable labeling methods in order to be used in downstream studies. Our goal was to establish methods suitable for mouse temporal bone 3D reconstruction using tissue optical clearing methods suitable for single-cell histological analysis.
Methods: Whole temporal bones of C57BL6J, Casp3 knockout and transgenic Cib2 mice were fixed, decalcified, labeled and optically cleared. We modified clearing protocols/reagents, SeeDB and Sca/eS, to be suitable for the mouse temporal bone. Imaging was obtained using Zeiss Lightsheet Z.1 lightsheet microscope, two-photon microscope, or light microscope, and 3D reconstruction was obtained using Imaris, Arivis or Fiji software. We used the 3D reconstructed images to determine the spatial planar orientation of the utricle and saccule as an example of a downstream application.
Results: We successfully cleared and 3D reconstructed the mouse temporal bone. We determined the planar orientation of the utricle and the saccule to be approximately 53 ± 8 degrees.
Conclusions: Many labeling methods can be successfully used in combination with tissue clearing, imaging and 3D reconstruction in the mouse temporal bone. We hope to use the whole temporal bone optical clearing in combination with vestibular functional studies.
PP1-18 - Selective otolith organ dysfunction in patients with non-spinning vertigo
3. Autonomic Function and Vestibular Disorders
Bin Luo
1
Jingwu Sun1, Zhu Zhao1, Ruirui Guan1
1 Anhui Provincial Hospital, The First Affiliated Hospital of University of Science and Technology of China, Department of Otolaryngology Head and Neck Surgery, China
Purpose: To elucidate the correlation of non-spinning vertigo symptom with the otolith organ dysfunction in patients with sudden deafness.
Methods: We reviewed the clinical records of 86 patients with sudden deafness and divided them into three groups according to the symptom of vertigo: sudden deafness without vertigo group (n = 36), sudden deafness with non-spinning vertigo group (n = 18) and sudden deafness with spinning vertigo group (n = 32). All the patients underwent testing of cervical and ocular vestibular evoked myogenic potentials (cVEMPs and oVEMPs), caloric testing and video head impulse testing (vHIT).
Results: The abnormal rates of VEMPs (either cVEMPs or oVEMPs or both), vHIT and caloric testing were 36.1%, 19.4%, 38.9% in the sudden deafness without vertigo group, 83.3%, 11.1%, 11.1% in the sudden deafness with non-spinning vertigo group and 75%, 68.8%, 78.1% in the sudden deafness with spinning vertigo group.
Conclusions: The symptom of non-spinning vertigo can be caused by selective otolith organ dysfunction.
PP1-19 - The effect of distraction on motion sickness
3. Autonomic Function and Vestibular Disorders
Art Mallinson
1
Gilles Bosser2, Lillian Wong3, Gaelle Quarck4, Philippe Perrin5
1 University of British Columbia, Department of Surgery; Vancouver General Hospital, Vancouver, CANADA
2 University Hospital, Department of Pediatric Cardiology, Nancy FRANCE
3 University of British Columbia, Department of Surgery; Vancouver, CANADA
4 Normandie University, Department of Chronobiologie, Caen, FRANCE
5 University Hospital of Nancy, Department of Pediatric Otolaryngology, -Nancy, FRANCE.
Purpose: Motion sickness (MS) can affects children, sailors, rally car drivers, fishermen and astronauts. Motion sickness is of vestibular origin, likely otolithic and newly developed symptoms suggest an abnormality in the structures.
Traditional theories about motion sickness have suggested a “sensory conflict”. Reading a book or an electronic reader in a car will increase the conflict and invoke the related symptoms. However some anecdotal observations by us have revealed that engaging in interactive video games in a car can actually serve to reduce these symptoms.
Methods: We developed a questionnaire for children in English and in French for normal children and their parents to ask them about their habits in the car. This included activities in a car, and also the structure of the vehicle they are in, the type of travel undertaken and the length of trip.
Results: Our long term study has shown that there are many different aspects of vehicle travel that can affect motion sickness, there are certain controllable factors that can alleviate those symptoms.
Conclusions: Although this study was carried out in normal children engaged in daily vehicle travel, we feel the information can be translated into a further understanding of motion sickness in other activities, such as rally car driving or deep-sea fishing, as well as in the patient with vestibular pathology complaining of newly developed motion sickness. All of these situations are a set of symptoms arising from the balance system.
PP1-20 - Efficacy of the Gufoni maneuver for treating the horizontal canal BPPV
4. Benign Paroxysmal Position Vertigo
Yasuo Ogawa
1
Takashi Iwasawa1, Koji Otsuka2, Taro Inagaki2, Noriko Nagai2, Mamoru Suzuki2
1 Tokyo Medical University Hachioji Medical Center, otorhinolaryngology, Japan
2 Tokyo Medical University, otorhinolaryngology, Japan
Purpose: To investigate the therapeutic efficacies of Gufoni maneuver in geotropic and apogeotropic type of the horizontal canal variant of benign paroxysmal positional vertigo (HC-BPPV),
Methods: Twenty five patients (19 women and 6 men, age range: 14-88 years, mean age 66.9 years) with HC-BPPV were included in this study. All patients had bi-directional-changing positional nystagmus, 13 patients with geotropic type and 12 with apogeotropic type. We underwent Gufoni maneuver immediately after diagnosis. We evaluated the number of days to resolution of nystagmus and symptom.
Results: After the first session of Gufoni maneuver, 2 patients with geotropic type nystagmus switched to apogeotropic type and 7 patients with apogeotropic type switched to geotropic type. The number of resolution days of geotropic type were 4-42days (average 11.4days), on the other hand, the number of resolution days of apogeotropic type were 11-183 days (average 70.3 days).
Conclusions: In geotropic type, patients with no switch to apogeotropic type were easy to resolution. In apogeotropic type, the patients who switch to geotropic type were easy to resolution; on the other hand, patients with no switch to geotropic type took long time to resolution. Although there are intractable cases, Gufoni maneuver is worth to perform.
PP1-21 - 25 (OH) D3 levels, incidence and recurrence of different clinical forms of BPPV
4. Benign Paroxysmal Position Vertigo
Anamarija Sestak1
Sinisa Maslovara
2
1 Department of Otolaryngology, County General and Veterans Hospital, Vukovar, Croatia
2 Department of Otorhinolaryngology and Maxillofacial Surgery, Medical Faculty, University of Osijek, J. Huttlera 4, Osijek 31 000, Croatia
Purpose: The aim of this study was to measure the serum levels of 25-hydroxyvitamin D3 (25-OH D3) in patients with BPPV and determine whether there is a difference in the serum levels of vitamin D3 between patients with and without recurrence, as well as between the different clinical forms of BPPV.
Methods: The study included 40 patients diagnosed with PC-BPPV based on the positive Dix-Hallpike’s test. All patients underwent Epley manoeuvre after the diagnosis. Patients were classified according to current guidelines for levels of vitamin D3 in the serum in three groups: the deficiency, insufficiency and adequate level.
Results: The average serum level of 25-OH D3 among respondents was 20.78 ng/mL, indicating a lack or insufficiency of the aforementioned 25-OH D3. According to the levels of 25-OH D3, most patients suffer from deficiency (47.5%). 7 (17.5%) respondents had adequate blood level of 25-OH D3, and 14 (35%) respondents suffer from insufficiency. A significant difference was not found in the serum level of 25-OH D3 between patients with and without BPPV recurrence. There was a significant difference in the serum levels of 25-OH D3 in comparison to the clinical form of the disease. Lower 25-OH D3 values were found in patients with canalithiasis compared to those with cupulolithiasis.
Conclusions: Given that the largest number of patients has decreased values of 25-OH D3, it is recommended that all patients diagnosed with BPPV have 25-OH D3 levels measured and in the event of reduced values implemented adequate replacement therapy.
PP1-22 - Accuracy of Questionnaire-Based Diagnosis of Benign Paroxysmal Positional Vertigo
4. Benign Paroxysmal Position Vertigo
Hyo-Jung Kim
1
Jin-Ok Lee2, Jeong-Mi Song2, Seo Won Oh2, Ji-Soo Kim2
1 Research Administration Team, Seoul National University Bundang Hospital, Seongnam, Korea.
2 Dizziness Center, Seoul National University Bundang Hospital, Seongnam, Korea
Purpose: To develop an algorithm for self-diagnosis of benign paroxysmal positional vertigo (BPPV) using a simple questionnaire that is feasible for self-administration of an appropriate canalith repositioning procedure (CRP) when BPPV recurs.
Methods: We developed a questionnaire that is consisted of six questions, the first three to diagnose BPPV and the following three to determine the involved canal and type of BPPV. From 2016 to 2017, 578 patients with dizziness completed the questionnaire before the positional tests using a video-oculography at the outpatient Dizziness Clinic of Seoul National University Bundang Hospital.
Results: Of the 578 patients, 200 were screened to have BPPV and 378 were decided to have dizziness/vertigo due to disorders other than BPPV based on the results of questionnaire. The sensitivity and specificity of the questionnaire for diagnosis of BPPV were 87% and 90% respectively. Of the 200 patients with a questionnaire-based diagnosis of BPPV, 30 failed to respond the Q4-6 to determine the involved canal and type of BPPV. The questionnaire and positional tests showed the same results on the subtype and affected side of BPPV in 121 patients (60.5%). Cohen’s Kappa indicates a substantial agreement (Kappa index =0.673) between the questionnaire and positional tests. Overall, the questionnaire could identify the affected canal and type accurately in 121 (65%) of the 185 patients with confirmed BPPV on positional tests.
Conclusions: The accuracy of questionnaire-based diagnosis of BPPV is acceptable, and self-treatment of BPPV may be first attempted by adopting an appropriate CRP based on the results of questionnaire.
PP1-23 - Apogeotropic variant of posterior semicircular canal benign paroxysmal positional vertigo
4. Benign Paroxysmal Position Vertigo
Giacinto Asprella Libonati1
Rudi Pecci
2
1 Giovanni Paolo II Hospital, Unit of Vestibology and Otorhinolaryngology, Policoro (MT), Italy Viale Salerno, 75025 Policoro (MT) Italy
2 Azienda Ospedaliero-Universitaria Careggi, Neuromusculoskeletal and Sensory Organs Department, Unit of Audiology, Florence, Italy
Purpose: The aim of this study is to verify that debris could sometimes localize into PSC close to the common crus, thus configuring the apogeotropic PSC-BPPV, characterized by torsional down beating-paroxysmal positional nystagmus (TDB-PPN) in Dix-Hallpike position, and to allow the differential diagnosis from Anterior Semicircular Canal (ASC) BPPV, characterized by the same nystagmus direction.
Methods: From January to August 2014 we selected 28 patients complaining of positional vertigo with TDB-PPN in Dix-Hallpike position. All of them were submitted to specific physical therapies aimed to cure apogeotropic PSC-BPPV: in 23 patients we used a liberatory manoeuvre, in 5 patients we used a forced prolonged position. All patients were checked within three days.
Results: The liberatory manoeuvre was effective in 20 out of 23 patients: 13 patients completely recovered and 7 showed a typical PSC-BPPV torsional up-beating paroxysmal positional nystagmus (TUB-PPN). The forced prolonged position had a positive outcome in 3 of 5 patients: one patient was symptoms and signs free and 2 had a typical TUB-PPN.
Conclusions: The described therapeutic techniques were successful in 82.1% of cases, either recovering the apogeotropic PSC-BPPV or transforming it in a typical PSC-BPPV form. Our study confirms both ASC BPPV and apogeotropic PSC-BPPV can manifest with identical TDB-PPN. The TDB-PPN recovery or its transformation into typical PSC-BPPV with TUB-PPN, allow us to distinguish ASC-BPPV from PSC-BPPV apogeotropic variant.
PP1-24 - Asking about dizziness when turning in bed predicts benign paroxysmal positional vertigo
4. Benign Paroxysmal Position Vertigo
Ellen Lindell
1
Caterina Finizia1, Mia Johansson2, Therese Karlsson1, Jerker Nilson3, Måns Magnusson4
1 Sahlgrenska University hospital, Department of Otolaryngology, Head and Neck Surgery, Gothenburg, Sweden
2 Sahlgrenska University hospital, Department of oncology, Gothenburg, Sweden
3 Södra Älvsborgs Hospital, Borås, Sweden
4 Lunds University, Department of Otorhinolaryngology Head and Neck surgery, Clinical Sciences, Lund, Sweden
Purpose: This study aims to assess useful questions when suspecting benign paroxysmal positional vertigo (BPPV) caused dizziness as well as identifying if a single question can usefully identify or distinguish patients with BPPV from other dizziness aetiology.
Methods: A total of 149 patients were included in the study. Patients admitted to the Ear, Nose and Throat department due to complaints of dizziness or vertigo were included. The patients answered a study-specific questionnaire and were investigated with Dix-Hallpike manoeuvre and the supine roll test. The diagnosis of BPPV was set following a positive Dix-Hallpike manoeuvre or supine roll test including presence of canal specific nystagmus.
Results: Two of the 17 questions were of diagnostic importance. Dizziness when laying down or turning over in bed, increased the likelihood of a BPPV diagnosis by an odds ratio (95% CI) of 60 (7.47-481.70) and identified patients with a clinical diagnosis of BPPV at 98% sensitivity and 60% specificity. Continuous dizziness duration as opposed to lasting seconds decreased the likelihood of BPPV with an odds ratio of 0.06 (0.01-0.27).
Conclusions: Dizziness when turning in bed is highly correlated to BPPV. A negative response to the question of dizziness in bed was 98% accurate in ruling out BPPV in a sample with a 39% prevalence. Vertiginous attacks when turning or laying down in bed together with dizziness < 1 minute, are important questions when taking a medical history and may help to early identify BPPV, also for non-medical staff, as well as reduce the need of further investigations.
PP1-25 - Canalith jam of the horizontal canal masquerading as acute vestibular loss: role of the video-HIT
4. Benign Paroxysmal Position Vertigo
Andrea Castellucci 1,2
1
Pasquale Malara 32, Cristina Brandolini 13, Valeria Del Vecchio 13, Giovanni Carlo Modugno 13, Angelo Ghidini4, Antonio Pirodda 13
1 1. ENT & Audiology Unit, DIMES, Sant’Orsola – Malpighi University Hospital, Bologna, Italy. 2. ENT Unit, Department of Surgery, AUSL – IRCCS, Reggio Emilia, Italy.
2 3. ENT Unit, Audiology & Vestibology Service, Centromedico, Bellinzona, Switzerland.
3 1. ENT & Audiology Unit, DIMES, Sant’Orsola – Malpighi University Hospital, Bologna, Italy.
4 2. ENT Unit, Department of Surgery, AUSL – IRCCS, Reggio Emilia, Italy.
Purpose: The differential diagnosis in case of spontaneous horizontal nystagmus (SHN) can be challenging. Thanks to the introduction of the video head impulse test (vHIT), peripheral SHN can be easily differentiated from SHN of central origin. Moreover, diagnosis of selective, partial or total loss of vestibular sensors/afferents can be made by matching vHIT data with cervical- and ocular-VEMPs results. We present a case of SHN where vHIT allowed to hypothesize a spontaneous plug due to a canalith jam as possible underlying mechanism.
Methods: A 74-year old woman presented with a history of acute vertigo, left-beating SHN and a clinical picture consistent with right peripheral acute vestibular loss. Bithermal caloric test (BCT) revealed a severe right unilateral weakness (90%). Nevertheless, both cervical- and ocular-VEMPs were symmetrical and vHIT revealed an isolated hypofunction of the right horizontal canal (RHC).
Results: After repeated head-roll maneuvers, bilateral positional paroxysmal geotropic horizontal nystagmus was evoked by Pagnini-McClure maneuvers suggesting BPPV involving the non-ampullated arm of the RHC. Restitution of RHC function after repositioning maneuvers was confirmed by vHIT and BCT. A spontaneous canalith jam affecting the RHC, leading to an isolated and transitory canal pseudo-areflexia, could be likely responsible for the presenting signs.
Conclusions: An extensive assessment of vestibular sensors and afferents should always be given in case of SHN. A canalith jam should be considered in case of selective canal dysfunction on vHIT. Similarly, canalith jam of vertical canals could likely account for selective and transient canal dysfunctions leading to spontaneous torsional nystagmus, generally considered of central origin.
PP1-26 - Characteristics of the Recurrence of Idiopathic Benign Paroxysmal Positional Vertigo
4. Benign Paroxysmal Position Vertigo
Yongsheng Tian
1
1 Department of Otolaryngology Head and Neck Surgery, Aerospace Center Hospital, Beijing, China
Purpose: To investigate the clinical features of the recurrence of idiopathic benign paroxysmal positional vertigo (IBPPV) patients. MethodsPatients with IBPPV were enrolled and were followed-up for 36 months after being well controlled. The data of the patients including age, gender, and co-morbidities (hypertension, diabetes, hyperlipidemia,) were analyzed. Characteristics of the recurrent BPPV were compared with those of the former onset.
Methods: Patients with IBPPV were enrolled and were followed-up for 36 months after being well controlled. The data of the patients including age, gender, and co-morbidities (hypertension, diabetes, hyperlipidemia,) were analyzed. Characteristics of the recurrent BPPV were compared with those of the former onset.
Results: Two hundred and one patients were enrolled in study and twenty two (10.5%) patients presented recurrent IBPPV within 36 months. Among them, about 16% showed changes in the involved semicircular canals. 50% recurrence occurred within 6 months after the first treatment. The recurrence rate of BPPV in 5060 years old patients(50%) is higher than other patients (P =0.018). Both the gender, and co-morbidities (hypertension, diabetes, hyperlipidemia) showed no significant difference between the two groups.
Conclusions: The incidence of recurrence in idiopathic BPPV patients was 10.5% in the present study. The mean period of 50% recurrence after a symptom-free interval was about 6 months. Furthermore, about 50% of patients suffered from recurrence of idiopathic BPPV at a different type of canal from the semicircular canal of the initial idiopathic BPPV attack. Age but not gender or co-morbiditie might be correlated with BPPV recurrence.
PP1-27 - Characteristics and recurrent risks of Benign Paroxysmal Positional Vertigo in young and elder group
4. Benign Paroxysmal Position Vertigo
Cuiting Zhu
1
Ju Yi1, Xing quan zhao1, Wang Yan2, Meimei Chen2, Cui Yu2
1 Beijing Tian Tan Hospital, Capital Medical University, Vascular Neurology Center Department of Neurology, Beijing
2 Beijing Tian Tan Hospital, Capital Medical University, Department of Neural Electrophysiology, Beijing
Purpose: To investigate the characteristics and recurrent risk of the Benign Paroxysmal Positional Vertigo (BPPV) in young and elder patients.
Methods: A total of 354 patients with BPPV treated and completed follow-up in our clinic between January 2010 to June 2015were enrolled,including 127 patients aging from 18 to 45 years old (young group) and 227 patients more than 60 years old (elder group). The characteristics and recurrent risks of BPPV in young and elder patients were evaluated.
Results: There were 58 males and 69 females in young group, and 81 males and 146 females in elder patients, with no significant difference in gender between two groups (P=0.065). There were no significant difference in the frequency of cases with Meniere’s disease, sudden hearing loss, migraine, head trauma, and history surgery (P0.05).But the prevalence of hypertension, hyperlipemia, diabetes, coronary heart disease, arterial plaque and cerebral infraction in elder group was higher than in young group (P0.05). The recurrent rate of BPPV one month after repositioning maneuvers was 16.5% in young group and 29.1% in elder group, with significant difference (P=0.0090.05). Meniere’s disease and hypertension are independent risk factors of the recurrence of BPPV in elder group.The recurrence of the elder than 60 year-old BPPV group combining with 0,1,≥2 cerebrovascular disease risk factors respectively is 7.5%,10.7%, 47.4%.
Conclusions: The prevalence of hypertension, hyperlipemia, diabetes, coronary heart disease, arterial plaque and cerebral infraction in elder group was higher than in young group. Meniere’s disease and hypertension are independent risk factors for the recurrence of BPPV in elder group.
PP1-28 - Characteristics of Benign Positional Vertigo Tested on the Epley Omniax Chair
4. Benign Paroxysmal Position Vertigo
Emma Argaet1
Corinna Lechner1, Andrew Bradshaw1,
Benjamin Nham1, G. Michael Halmagyi1, Miriam S. Welgampola1
1 University of Sydney Australia
Purpose: To describe the spatiotemporal characteristics of BPV and its variants.
Methods: We studied 2559 consecutive patients referred to a neuro otology clinic dedicated to the management of BPV. Patients were tested on the Epley Omniax Rotator, a positioning device which allows alignment of the patient in the plane of any given canal and simultaneously display and records video oculography. Video data was extracted and analysed offline using a custom written LabVIEW programme. Nystagmus onset, duration and slow phase velocities were analysed.
Results: BPV was diagnosed in 1207 subjects: 814 had unilateral posterior-canalithiasis while 167 had bilateral posterior-canal involvement and 72 patients had more than 2 canals affected; 96 patients had horizontal-canal BPV. In 11 patients anterior-canal BPV was found. In PC BPV, nystagmus onset occurred before 1second in 73% subjects. Nystagmus duration was 13.4 sec (median). The median peak-SPV was 32.4/sec. In horizontal-canalithiasis with the affected ear down, nystagmus onset was <1s in nearly all subjects. Nystagmus lasted for 22.5 sec (median) and peaked at 56.8/sec(median). When the unaffected ear was lowermost the nystagmus duration was similar 25 s (median) and peak-SPV 18.1/sec. In all subjects with canalithiasis, the time taken for the peak-SPV to halve (T50) was <60s. In contrast, subjects diagnosed with vestibular migraine (n=334) had persistant vertical or horizontal positional nystagmus with a T50 that exceeded 60s.
Conclusions: Canalithiasis uniformly demonstrated a crescendo decrescendo SPV profile. Symptomatic horizontal or vertical positional nystagmus recorded in canalithiasis could be separated from horizontal positional nystagmus recorded in vestibular migraine.
PP1-29 - Clinical analysis of benign paroxysmal positional vertigo with multiple canal involvement
4. Benign Paroxysmal Position Vertigo
Bo Shen
1
Xu Yang1
1 Department of Neurology, Aerospace Center Hospital, Peking University Aerospace School of Clinical Medicine, Beijing, China.
Purpose: To investigate the clinical features, diagnosis and treatment of multi-canal benign paroxysmal positional vertigo (BPPV).
Methods: 41 patients with multi-canal BPPV who received treatment between January 2015 and December 2017 were included in this study. All included patients were diagnosed according to the nystagmus as confirmed by videonystagmograph during the Dix-Hallpike, straight head hanging and Roll tests and treated according to the involvement of canal (Epley’s maneuver for the posterior canal, Yacovino maneuver for the anterior canal, Barbecue or Gufoni maneuver for the lateral canal).
Results: Among 267 patients with BPPV, 41 (15.4%) developed multi-canal BPPV. These 41 patients consisted of 15 (36.6%) males and 26 (63.4%) females, with an average age of 64.24 ±13.93. Seventeen patients (41.5%) had up-beating nystagmus with torsional components and horizontal nystagmus, suggesting BPPV involving both posterior and lateral canals. Eleven patients (26.8%) had up-beating nystagmus with torsional components and down-beating nystagmus with or without torsional components, suggesting BPPV involving both posterior and anterior canals. Eleven patients (26.8%) had down-beating nystagmus with or without torsional components and horizontal nystagmus, suggesting BPPV involving both anterior and lateral canals. Two patients (4.9%) had bilateral up-beating nystagmus with torsional components, suggesting BPPV involving bilateral posterior canals. Thirty-one (75.6%) of the patients were cured after one or two maneuvers. Thirty-seven patients (90.2%) were cured with an average of 2.1 therapeutic sessions per patient.
Conclusions: Multi-canal BPPV is not so rare, and the posterior and horizontal canals are involved in most cases. Repositioning maneuver is effective for multi-canal BPPV.
PP1-30 - Clinical characteristic and risk factor of canal conversion in benign paroxysmal positional vertigo
4. Benign Paroxysmal Position Vertigo
Geonho Lee
1
Jin-woong Choi1
1 Chungnam national university hospital, department of otorhinolaryngology, South Korea
Purpose: The purposes of this study were to investigate the incidence of canal conversion in benign paroxysmal positional vertigo (BPPV) and to analyze the risk factors and clinical features of the canal conversion.
Methods: We retrospectively reviewed medical chart in 2450 patients diagnosed with BPPV from March 2012 to December 2017. The following parameters were analyzed in patients with (canal conversion group) and without canal conversion (non-canal conversion group) after canalith repositioning procedure (CRP) for treatment: demographics including age and sex, etiology, side and type of semicircular canal involved, and type and number of CRP.
Results: Canal conversion occurred in 56 of total 2450 patients (2.3%). Demographic, etiology, and side of semicircular canal involved did not differ between the two groups. However, canal conversion occurred more commonly in the lateral semicircular canal (LC) than in the posterior semicircular canal, (PC) which was statistically significant (P = 0.003). There were no significant differences in those parameters in patients with and without canal conversion in the PC. In the LC, the parameters did not differ according to the presence of canal conversion. Furthermore, there was no difference in those parameters when analyzed by type of conversion.
Conclusions: There is no difference in the outcome of treatment, such as the number of CRP in patients with or without canal conversion, but canal conversion can occur in approximately 2.3% of BPPV patients. Moreover, the canal conversion is more common in LC than in PC, so the possibility of canal conversion should be considered in treating BPPV in LC.
PP1-31 - Demographics of patients with BPPV and treatment efficacy in the Singapore population
4. Benign Paroxysmal Position Vertigo
Lee Huan Tee1
Eu Chin Ho
1
1 Tan Tock Seng Hospital
Purpose: BPPV is one the commonest vestibular conditions. This study aims to investigate the demographics of BPPV patients and treatment efficacy for patients with BPPV by physiotherapists in Singapore.
Methods: 536 patients with BPPV referred for vestibular rehabilitation from 2004 to 2015 were retrospectively analysed. Patients were assessed with Dix Hallpike Test and Supine Roll Test (Pagnini-McClure) for vertical and horizontal canals BPPV respectively, and treated with appropriate repositioning maneuvers by three vestibular rehab-trained physiotherapists. Maneuvers were repeated, if vertigo and nystagmus persisted upon re-evaluation of tests until patients were asymptomatic or unable to tolerate further maneuvers. Successful treatment was determined by resolution of symptoms following re-evaluation of tests 1-2 weeks post treatment. The Dizziness Handicap Inventory (DHI) was also administered to evaluate the self-perceived handicap effects of dizziness pre and post treatment.
Results: The mean age onset of BPPV is 57 years. Females:male ratio = 2:1. 97% of patients have Canalithiasis is the most common type of BPPV (97%). Canal type was posterior (71%), horizontal (12%), anterior (6.5%) and indeterminate (9.7%).
The success rate of the repositioning techniques is 71% within 2 maneuvers within a single treatment session. 98% of all patients are symptom free after repositioning within 3 physiotherapy sessions. Compared to pre-treatment, there was a significant improvement in self-reported DHI scores post-treatment. (p = 0.000, p <0.05).
Conclusions: The demographics and treatment effectiveness of patients with BPPV for the Singapore population is high and comparable with other populations.
PP1-32 - Diagnosis and Treatment of Anterior Canal Benign Paroxysmal Positional Vertigo
4. Benign Paroxysmal Position Vertigo
Xia Ling
1
Xu Yang1
1 Department of Neurology, Aerospace Center Hospital, Peking University Aerospace School of Clinical Medicine, Beijing, China.
Purpose: To investigate the diagnosis and treatment of anterior canal benign paroxysmal positional vertigo (AC-BPPV).
Methods: Forty patients (14 males and 26 female) diagnosed with AC-BPPV were enrolled. All patients were diagnosed based on the presence of nystagmus during the Dix-Hallpike (D-H), straight head hanging (SHH) and Roll tests and were treated by Yacovino maneuver.
Results: In the D-H test, down-beating nystagmus (DBN), and DBN with torsional components were observed in 22 and 18 patients, respectively. In the SHH, DBN, and DBN with torsional components were observed in 37 and 3 patients, respectively. The type of nystagmus evoked through D-H and SHH tests was statistically different (P<0.05).The right and left sides AC-BPPV were 17 (42.5%) and12 (30%), and 11 patients (27.5%) were not clear the affected side.11 patients had combined the posterior canal BPPV, and 11 patients had combined horizontal canal BPPV. 39 patients (1 patient were treated before and recovered) were treated by Yacovino maneuver. 34 patients (87.1%) were cured after treatment for an average 1.8 times. Diagnosis method: 17 patients were diagnosed by the effectiveness of treatment, 20 patients were diagnosed by the combination of other canal typical BPPV, and 3 patients were diagnosed by the canal conversion during follow-up.
Conclusions: D-H often evoke DBN with torsional component, and is more beneficial to identify the affected side of AC-BPPV compared with the SHH. The effectiveness of Yacovino maneuver, the presence of typical BPPV, canal conversion phenomenon and follow-up outcomes contribute to the diagnosis of AC-BPPV. Yacovino maneuver was effective in AC-BPPV patients.
PP1-33 - Effect of Intratympanic Steroid Injection in Light Cupula
4. Benign Paroxysmal Position Vertigo
Jin Su Park
1
Min-Beom Kim2
1 Department of Otorhinolaryngology-Head and Neck Surgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine
2 Department of Otorhinolaryngology-Head and Neck Surgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
Purpose: To evaluate the effects of intratympanic steroid injection in light cupula.
Methods: 47 patients with persistent geotropic direction changing positional nystagmus with null point (light cupula) participated in this study. All study populations were randomly classified into three groups on initial visit day: the intratympanic steroid injection (ITS, n=15) group, Vestibular supressant (VS, n=16) group (treated with a vestibular suppressant [dimenhydrinate 50 mg per day for 1 week]) and canalith repositioning procedures (CRP, n=16) group. Positional nystagmus, dizziness handicap inventory (DHI) questionnaires and dizziness severity by visual analogue scale (VAS) were completed before and after each treatment.
Results: The DHI score before treatment in ITS, CRP and VS groups were 35.8, 34.06, and 34.75, respectively. At 1 week after the 1st treatment, the score had statistically significantly decreased in all groups. But, there were no differences among three groups. At 1 week after the 1st treatment, patients who showed resolution of persistent geotropic DCPN in ITS, CRP and VS groups were 7, 6 and 7, respectively. There were no significant differences between three groups. In ITS group only, however, reversal of stronger side on head roll test after each treatment was observed in 6 patients, and 2 out of 6 patients showed early resolution of DCPN at 3rd day.
Conclusions: ITS was not significantly effective for the light cupula at 1 week follow up. But, some patients of ITS group showed reversal of stronger side in DCPN on head roll test and resolution of DCPN at earlier follow up.
PP1-34 - Efficacy of Gufoni maneuver and head-shaking for treating apogeotropic horizontal BPPV
4. Benign Paroxysmal Position Vertigo
Liying Chang
1
1 Xiangyang Central Hospital, Affiliated Hospital Of Hubei University of Arts and Science. Xiangyang, Hubei province, China. 441021
Purpose: To evaluate the efficacy of Gufoni maneuver and Head-shaking for treating apogeotropic horizontal benign paroxysmal positional vertigoHC-BPPV, a randomized, prospective study was conducted.
Methods: A total of 84 patients from October 2014 to October 2017 with apogeotropic HC-BPPV in the Dizziness Clinic in Xiangyang Center Hospital were randomly assigned to group AGufoni maneuver,n=29), group B (Head-shaking, n=28 and group C(Brandt-Daroff exercisen=27). These manuevers were performed once a day until the treatment success. Successful treatment was defined as disappearance of positional nystagmus or as transition into geotropic horizontal nystagmus.The efficacy were evaluated at the 1st hour, 3rd day and 1st week after treatment.
Results: The 1st hour after treatment, the successful cases of group A, B and C were respectively 15/29,15/28 and 7/27. The efficacy in group AP=0.048and group BP=0.036is better than that in group C, but there was no difference between group A and group B (P=0.889) .On the 3rd day, the success rate of group A,B and C were respectively 82.76%, 85.71% and 62.96%, the therapeutic effect between group A and B P=0.760A and CP=0.095B and CP=0.053 had no significant difference.One week after treatment, the success rate of group A, B and C were respectively 93.10%, 92.86% and 77.78%, the therapeutic effect between group A and B (P=0.971)A and C(P=0.101), B and C(P=0.113) had no difference.
Conclusions: Both Gufoni maneuver and Head-shaking are effective treatment for apogeotropic HC-BPPV and they are better than B-D exercise at immediate (1 hour) effect. However, there is no difference between the three methods on the 3rd day and 1st week after treatment.
PP1-35 - Frequency tuning of ocular vestibular evoked myogenic potential in BPPV
4. Benign Paroxysmal Position Vertigo
Yongsheng Tian
1
Zufei Li1, Rong Ma1
1 Department of Otolaryngology Head and Neck Surgery, Aerospace Center Hospital, Beijing 100049, China
Purpose: The aim of this study was to investigate changes in the frequency tuning of the ocular vestibular evoked myogenic potential (oVEMP) in patients with idiopathic benign paroxysmal positional vertigo (IBPPV).
Methods: A total of 103 consecutively consenting patients with IBPPV were included in the study: 42 patients with horizontal semicircular canal IBPPV and 61 patients with posterior semicircular canal IBPPV. As normal controls, 30 age-matched healthy patients were enrolled in the study. The oVEMP were recorded using air-conducted tone bursts at 500 Hz and 1000 Hz, and the 500/1000 Hz amplitude ratio of oVEMP was determined.
Results: The 500/1000 Hz amplitude ratio of the N1-P1 wave complex of the oVEMP in the affected ears was significantly lower than that of the unaffected ears and normal control ears. The unaffected ears of the IBPPV subjects also showed a lower amplitude ratio compared to that of the healthy controls, but the difference was not statistically significant. No significant differences in the 500/1000 Hz amplitude ratio of the oVEMP were found between the Horizontal Canal IBPPV and Posterior Canal IBPPV patients.
Conclusions: IBPPV can affect the frequency tuning of ocular vestibular evoked myogenic potential and decrease the sensitivity of low-frequency sound signals in the utricular otolith organs.
PP1-36 - Idiopathic benign paroxysmal positional vertigo in the elderly: A long-term follow-up study
4. Benign Paroxysmal Position Vertigo
Seong-Ki Ahn
1
Hyun Woo Park1, Seong-Ghul Yeo1, Jin Hyun Seo1, Dae Hwan Kim1
1 Gyeongsang National University and Gyeongsang National University Hospital, Department of Otolaryngology, South Korea
Purpose: Benign paroxysmal positional vertigo (BPPV) is the most common cause of peripheral-type vertigo in the elderly. While some studies have investigated BPPV among the elderly, no study has focused on the isolated idiopathic BPPV (iBPPV) in the elderly.
Therefore, this study was to investigate the clinical features and recurrence rate in elderly patients diagnosed with iBPPV.
Methods: The authors prospectively reviewed the medical records of 627 patients diagnosed with BPPV, and a total of 370 patients fulfilled the inclusion criteria. The subjects were divided into two groups by age (experimental group ≥65 years and control group 17-64 years), and the gender, numbers of canalith reposition maneuver (CRM) for successful treatment, time elapsed from onset of symptoms to clinic visit, the affected semicircular canal, and the 1- and 5-year recurrence proportion were analyzed.
Results: The gender, numbers of CRM for successful treatment, affected semicircular canal, and the 1- and 5-year recurrence proportion showed no statistically significant difference between two groups (p > 0.05). The only exception was the experimental group which took a longer duration from manifestation of symptoms to hospital visit than control group (student’s t test, p = 0.021).
Conclusions: The elderly with iBPPV could be treated as effective as general population.
PP1-37 - Immediate efficacy of Gufoni maneuver for HC-BPPV: a meta-analysis
4. Benign Paroxysmal Position Vertigo
Wei Fu
1
Dong Wei2
1 Fourth Military Medical University, Xijing Hospital, Department of Geriatrics, China
2 Fourth Military Medical University, Xijing Hospital, Department of Neurology, China
Purpose: Gufoni maneuver is a very common and efficient treatment for horizontal canal benign paroxysmal positional vertigo (HC-BPPV), with which patients with either a canalolithiasis or a cupulolithiasis can be successfully treated. However, there is no evidence-based study to reveal the immediate efficacy of this maneuver for HC-BPPV. Therefore,This meta-analysis aims to systematically measure the immediate efficacy of the Gufoni maneuver for HC-BPPV.
Methods: A extensive search electronic databases,including PubMed, Embase, Web of Science, Cochrane and Chinese medical databases, were searched until to September 1, 2017 for relevant articles. we selected only randomized clinical trials studying with treatment of HC-BPPV employ by the Gufoni maneuver.
Results: Six randomized clinical trials were included in the current meta-analysis with a total of 696 HC-BPPV patients. The pooled odds ratio of efficacy (ORe) and odds ratio of otolith switch (ORos) were used to estimate overall therapeutic performance. The pooled ORes were 4.00 (95% CI, 2.05-7.78, p<0.01, Gufoni VS. Sham), 1.87(95% CI, 0.42-8.33, p=0.41, Gufoni VS. Barbecue maneuver), while the pooled ORos was 2.17(95% CI, 0.55-8.53, p=0.27). Subgroup analyses showed that the respective pooled ORes were 3.51(95% CI,2.09-5.89, p<0.01) and 3.23(95% CI, 1.24-8.39, p<0.05) in groups of geotropic nystagmus and geonegative nystagmus.
Conclusions: Gufoni maneuver has a satisfactory immediate efficacy for HC-BPPV and doesn’t increase otolith switch.
PP1-38 - Objective Characteristics of Nystagmus in Posterior Semicircular Canal BPPV
4. Benign Paroxysmal Position Vertigo
xu kaixu
1
chen taisheng1, wang wei1
1 Tianjin first hospital, Otolaryngology head and neck surgery, China
Purpose: To analyze and discuss the clinical characteristics and mechanism of nystagmus direction, latency, duration time and intensity in posterior semicircular canal benign paroxysmal positional vertigo.
Methods: Subjects in the study were 564 patients with Posterior Semicircular Canal CanalithasisPSC-CanBPPV. The induced nystagmus in Dix-Hallpike test was recorded by video nystagmuo graph(VNG)and the direction, latency, duration time and intensity characteristics of nystagmus were compared in hanging and sitting
Results: Vertical torsional nystagmus were both induced by hanging and sitting in Dix-Hallpike test. The vertical direction of the induced nystagmus is upward and downward respectively. The latency, duration time and intensity turning to lesion side were L2.65±1.92; 1.44±1.24D14.90±10.46; 15.28± 8.06P29.75±21.26; 14.08± 9.48. The latency, and intensity in hanging were larger than sit. The intensity rate is about 2:1,the difference is statistically significant. The direction of the induced nystagmus is opposite to turning in HSC-Can BPPV. The intensity turning to normal side were larger than lesion side obviously. The intensity rate is about 2:1, the difference is statistically significant (t=17.296, P0.01)
Conclusions: a.The nystagmus intensity rate in Dix-Hallpike test of hanging to lesion side in PSC-Can was 2:1, following Ewald’s law; b. BPPV is either a disease, or a physical model to study the single semicircular-nystagmus effect; c.These nystagmus parameters of VNG in Dix-Hallpike test is an objective guideline for BPPV diagnose.
PP1-39 - Optimal reassessment timing after treatment in posterior canal benign paroxysmal positional vertigo
4. Benign Paroxysmal Position Vertigo
Dae Bo Shim
1
Junhui Jeong2
1 Myongji Hospital, Department of Otorhinolaryngology, South Korea
2 National Health Insurance Service Ilsan Hospital, Department of Otorhinolaryngology, South Korea
Purpose: The aim of this study is to evaluate the optimal reassessment time for treatment response in posterior canal benign paroxysmal positional vertigo (p-BPPV) following the initial Epley maneuver.
Methods: This is a prospective, single-blinded, randomized study that included 108 patients with p- BPPV who agreed to participate. All patients included in the study received a single modified Epley maneuver (recommended by the 2008 AAO guideline) daily until the positional nystagmus disappeared during the Dix-Hallpike maneuver 24 hours after the treatment. Repeated Dix-Hallpike testing to reassess the treatment response was performed at 1 hour (post-1 hr), every 24 hours (post-24 hr) until resolution of positional nystagmus, 1 week (post-1 wk), and 1 month (post-1 mo) following the therapeutic maneuver. The difference in the resolution rate at post-1 hr and post-24 hr reassessment was analyzed and the recurrence rates at post-1 wk and post-1 mo were evaluated.
Results: The resolution rate was 67.6% at post-1 hr which increased to 79.6% at post-24 hr reassessment. There was statistically significant difference in the results of the Dix-Hallpike test between post-1 hr and post-24 hr follow-up. After complete resolution, nine of 108 patients (8.3%) demonstrated recurrence within 1 month.
Conclusions: Reassessment after 24 hours following the initial Epley maneuver is more advantageous than 1-hour follow-up in patients with p-BPPV. This information may provide helpful guideline for clinicians in deciding the appropriate follow-up period after treatment in p-BPPV.
PP1-40 - Positional downbeat nystagmus in posterior canal benign paroxysmal positional vertigo
4. Benign Paroxysmal Position Vertigo
Eun Hye Oh
1
Jae-Hoon Lee1, Hyo-Jung Kim2, Seo-Young Choi3, Kwang-Dong Choi3, Jae-Hwan Choi1
1 Pusan National University Yangsan Hospital, Neurology, South Korea
2 Seoul National University Bundang Hospital, Research Administration Team, South Korea
3 Pusan National University Hospital, Neurology, South Korea
Purpose: To assess the incidence and clinical significance of positional downbeat nystagmus (pDBN) after treatment of posterior canal benign paroxysmal positional vertigo (PC BPPV).
Methods: We have recruited 77 patients with a diagnosis of PC BPPV. After Epley manueuver, we assessed the presence of DBN during follow-up positional tests. We compared clinical characteristics between pDBN (+) and pDBN (-) group in patients with successful treatment.
Results: Of 57 patients with successful treatment, 22 (39%) showed pDBN during one hour follow-up tests. The mean latency and duration of pDBN were 3.2 ± 2.0 and 12 ± 10.0 s (mean ± SD), respectively. The maximal SPV of pDBN ranged from 2.0 to 12.2 degree (mean ± SD = 5.1 ± 2.5 degree). A torsional component was detectable in six patients. At one week follow-up, there was no difference in the questionnaires scores between pDBN (+) and pDBN (-) group, but a recurrence rate was significantly higher in pDBN (+) group (5/22, 23%) than pDBN (-) group (1/31, 3%, p=0.036). pDBN disappeared in all patients within 6 months.
Conclusions: Our study shows that transient pDBN can be observed in 40% of patients after a successful treatment of PC BPPV. The patients with pDBN showed a high tendency of recurrence within one week. The pDBN may be caused by the remaining debris in the distal portion of the PC, which can move towards the ampulla producing an ampullopetal endolymphatic flow during positioning.
PP1-41 - Relationship between clinical features and therapeutic approach in benign BPPV outcomes
4. Benign Paroxysmal Position Vertigo
Koji Otsuka
1
Yasuo Ogawa1, Taro Inagaki1, Shigetaka Shimizu1, Ujimoto Konomi1, Noriko Nagai1, Eriko Sakurai1, Shigeto Itani1, Mamoru Suzuki1
1 Tokyo Medical University, Department of Otolaryngology, Japan
Purpose: To examine the age and gender distribution of patients, clinical features, treatment methods and outcomes of benign paroxysmal positional vertigo.
Methods: We reviewed 357 BPPV patients for 5 years. Posterior canal BPPV patients were divided into 2 groups, one underwent the Epley manoeuvre and the other received medication. Lateral canal canalolithiasis patients were divided into 2 groups, one underwent the Lempert manoeuvre and the other received medication.
Results: In the posterior canal BPPV group, the average resolution time was 9.6 days. The average resolution time was 7.7 days in the Epley manoeuvre group and 14.1 days in the medication group. In the lateral canal canalolithiasis group, the average resolution time was 11.1 days. The average resolution time was 8.3 days in the Lempert manoeuvre group and 13.4 days in the medication group. In the lateral canal cupulolithiasis group, the average resolution time was 36.7 days.The average age at recurrence was 61.3 years at the 1st recurrence, 64.5 years at the 2nd recurrence, and 68.0 years at the 3rd recurrence. As the number of recurrences increased female gender predominance increased.
Conclusions: In posterior canal BPPV patients, the resolution time in the Epley manoeuvre group was significantly shorter than in the medication group. In lateral canal canalolithiasis patients, the resolution time in the Lempert manoeuvre group was significantly shorter than in the medication group. The resolution time was significantly longer in the lateral canal cupulolithiasis group than in other types of BPPV. As the number of recurrences increased, average age and female gender predominance increased.
PP1-42 - Residual dizziness after repositioning in BPPV with preexisting central neurologic disorders
4. Benign Paroxysmal Position Vertigo
Hsun-Hua Lee
1
Che-Hsuan Lin2, Hsiao-Shan Cho1, Chih-Chung Chen1
1 Taipei Medical University – Shuang Ho Hospital, Department of Neurology, Taiwan
2 Taipei Medical University Hospital, Department of Otolaryngology, Taiwan
Purpose: Diagnosis and treatment of BPPV in patients with preexisting central neurologic disorders is not always straightforward. Except for migraine, the effectiveness of repositioning treatment in patients with preexisting central neurologic disorders is not described before. In addition, the incidence of residual dizziness after successful repositioning treatment in this group remains unclear.
Methods: Clinical information of consecutive BPPV cases over a duration of 18 months are collected from specialized neurologic clinics in an academic university hospital. After excluding secondary cases, the remaining cases are classified into BPPV with preexisting central neurologic disorders (CND+) group and BPPV without preexisting central neurologic disorders (CND-) group. Age, gender, side of BPPV, involved canal, number of trials for successful repositioning and residual dizziness are compared between both groups.
Results: Clinical data of consecutive 108 cases are collected. Fifteen secondary cases and 1 lost follow-up are excluded. CND+ group comprises 29 cases (13 migraine, 11 cerebrovascular disease, 3 Parkinson disease, 1 restless leg syndrome, 1 orthostatic hypotension) and CND- group comprises 63 cases. Group comparisons (CND+ vs. CND-) show mean age 64.6 vs. 62.7 (p>0.05), female 89.6% vs. 63.5 % (p<0.05), right side 75.9% vs. 52.4% (p<0.05), posterior canal 86.2% vs. 66.7% (p>0.05), success within 2 trials of repositioning 100% vs. 92.1% (p>0.05) and residual dizziness 41.4% vs. 31.7% (p>0.05).
Conclusions: Similar to CND- group, CND+ group shows female, right side and posterior canal predominance. Number of trials needed to treat patients and incidence of residual dizziness are not significantly higher in BPPV patients with preexisting central neurologic disorders.
PP1-43 - The discussing between premier solution of Roll Test and Dix-Hallpike Test inBPPV
4. Benign Paroxysmal Position Vertigo
chen taisheng
1
wang wei1, xu kaixu1, Li Shanshan1, wen chao1, liu qiang1, lin peng1
1 Tianjin first center Hospital, Otolaryngology Head and Neck surgery, China
Purpose: To analyze the objective characteristics of Roll Test and Dix-Hallpike Test in benign paroxysmal positional vertigoBPPVpatientsdiscussing the premier solution of positional test.
Methods: A total of 230 patients with BPPVwhereas 170 PSC-Can BPPV and 60 HSC-Can BPPV were involved respectively. The induced nystagmus in Roll Test and Dix-Hallpike Test was recorded by video nystagmuo graph (VNG), and the direction, intensity and time characteristics of nystagmus were compared in various BPPV.
Results: Vertically upward nystagmus was induced by hanging in 170 PSC-Can Dix-Hallpike Test, and the nystagmus reversed and turned weaker when the subjects came to sit. The intensity of nystagmus at turning to lesion side by hanging and sit were (30.3±14.1)°/s and (12.6±7.5)°/s respectively. However, no nystagmus was induced in PSC-Can Roll Test. Horizontal nystagmus in the same direction with turning were induced in 60 HSC-Can Roll Test. The intensity of nystagmus at turning to lesion side and normal side were (42.0±18.0)°/s(20.3±8.7)°/s respectively. Furthermore, horizontal nystagmus in the same direction with turning were induced in 57 HSC-Can Dix-Hallpike. With the results of Roll Test for reference, the coherence is 95%.
Conclusions: Dix-Hallpike Test not only can be used to diagnose PSC-Can, but also induce nystagmus in HSC-Can effectively. Whereas the Roll Test only shown significance in diagnosing HSC-Can.
PP1-44 - Trial of a two-item questionnaire for identifying patients with Benign Paroxysmal Positional Vertigo
4. Benign Paroxysmal Position Vertigo
Jeremy Corcoran1
Simon Michalski1, Julian Ahmed1, Louisa Murdin1
1 Guy’s and St Thomas’ NHS Foundation Trust, Multidisciplinary Balance Clinic, London
Purpose: Benign paroxysmal positional vertigo (BPPV) accounts for 19% attendances at our specialist Multidisciplinary Balance Clinic (MBC). Patients with BPPV can often be managed with particle repositioning manoeuvres without need for complex MBC assessments. The aim of the study was to assess effectiveness of a postal screening tool and targeted intervention to identify and treat patients with BPPV.
Methods: Patients on the MBC waiting list in June 2017 were posted a brief paper questionnaire: • Do you experience dizziness when rolling over in bed? • Does this dizziness last less than 2 minutes? Patients with negative responses proceeded to full MBC assessment. Those who responded affirmatively to both questions were triaged to a designated physiotherapy clinic for focussed assessment. Patients diagnosed with BPPV were treated with particle repositioning manoeuvres. Patients without BPPV, and those identified as having additional complex presentations, proceeded to the MBC.
Results: 360 patients were sent questionnaires. 64 responded affirmatively to both questions and were offered appointments; of which 52 patients attended. 19 of these had positive positioning tests. 13 had a suggestive history but negative tests (62% in total). Of those with positive positioning tests, 10 (19% of those seen) were discharged without further intervention; the other 9 had residual symptoms despite successful BPPV treatment. Therefore 42 (81%) required further intervention.
Conclusions: A simple postal screening tool can identify patients with BPPV with a positive predictive value of 62%, allowing appropriate triage to a targeted clinic. However many such patients have needs which cannot be managed with repositioning alone.
PP1-45 - TRV Chair For Diagnosis and Treatment of BPPV
4. Benign Paroxysmal Position Vertigo
Harry Akram
1
1 Royal National Throat, Nose & Ear Hospital, London, UK.
Purpose: We investigate the diagnostic yield and treatment success rate of the TRV Chair for BPPV, which is thought to be the most common cause of vertigo in adults. Although the TRV Chair is not a recent innovation, it is not widely used in the UK and is under-studied.
Methods: We collected data from 150 patients reporting “positional vertigo” as a symptom by performing positional tests on the bedside directly followed by TRV Chair (and Video Frenzel) assessment. If indicated, subjects were treated with repositioning manoeuvres. Success was measured by complete resolution of symptoms and/or absence of nystagmus at follow up (2-4 weeks post-treatment). Treatment manouvres used were Epley, Semont and Lempert.
Results: Preliminary normative data suggests up to 5% of subjects who do not have vertigo will have some degree of positional nystagmus. 90% of patients reporting positional vertigo as a symptom were found to have positional nystagmus (and therefore BPPV). We report an 89% success rate for all subjects with positional nystagmus, 97% success for subjects who were identified without Video Frenzel technology and subsequently treated in the TRV Chair, and 100% success for those identified to have lateral canal BPPV.
Conclusions: The TRV Chair is a very effective method for treatment of BPPV, especially for the lateral canal form and recurrent, treatment resistant BPPV; further study requires comparison with Video Frenzel alone and comparison of long term recurrence rates compared to traditional methods. Preliminary data suggests BPPV may be even more common than previously documented.
PP1-46 - Use of the Brny Society criteria to diagnose benign paroxysmal positional vertigo
4. Benign Paroxysmal Position Vertigo
Qingxiu Yao
1
Qiang Song1, Hui Wang1, Haibo Shi1, Dongzhen Yu1
1 Shanghai Jiao Tong University Affiliated Sixth People’s Hospital
Purpose: We reviewed the classifications of different subtypes of benign paroxysmal positional vertigo and the problems we encountered using the diagnostic criteria of the Bárány Society.
Methods: Both the Dix–Hallpike maneuver and supine roll test were performed on 568 patients, and diagnoses were made based on patient history and the type of provoked nystagmus (if any). Next, the numbers of patients with each subtype and other parameters, including age and sex, were analyzed.
Results: Posterior semicircular canal BPPV (pc-BPPV) accounted for the largest proportion, followed by horizontal semicircular canal BPPV (hc-BPPV). Both anterior canal BPPV and multiple canal lithiasis BPPV were rare, and no patient was diagnosed with cupulolithiasis of the posterior canal.
Conclusions: pc-BPPV, hc-BPPV, and hc-BPPV-cu were the three major subtypes that could be definitively diagnosed, whereas the diagnoses of pBPPV and pBPPVsr require further investigation, with special attention being paid to appropriate differentiation and repositioning maneuvers.
PP1-47 - Utility of Bow and Lean Test in Predicting Subtype of Benign Paroxysmal Positional Vertigo
4. Benign Paroxysmal Position Vertigo
Chang-Hee Kim
1
Seongjun Choi1, Jung Eun Shin1
1 Department of Otorhinolaryngology-Head and Neck Surgery, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Republic of Korea
Purpose: To investigate the role of “bow and lean test” (BLT) in the diagnosis of benign paroxysmal positional vertigo (BPPV).
Methods: Between March 2015 and June 2017, we enrolled 113 patients with posterior semicircular canal (PSCC) BPPV, 74 patients with lateral semicircular canal (LSCC) canalolithiasis, 53 patients with LSCC cupulolithiasis, and 32 patients with light cupula. We retrospectively assessed bowing nystagmus (BN) and leaning nystagmus (LN).
Results: In PSCC BPPV, 75% of the patients showed at least one of BN and LN, and direction of nystagmus provoked by a Dix-Hallpike test on the affected side was consistent with that of LN and opposite to that of BN. In LSCC canalolithiasis, 65% (48 of 74) of the patients showed both BN and LN which were in the same direction in 38 patients (of 48) and in the opposite direction in 10 patients (of 48). The affected side can be determined according to the results of BLT in 74% (55 of 74) of LSCC canalolithiasis patients, and among them, the side determined according to the results of head-roll test was discordant with that according to BLT in 20 patients (of 55, 36%). In LSCC cupulopathy (n = 85), both BN and LN were persistent and observed in all cases, but we could not distinguish LSCC cupulolithiasis from light cupula according to nystagmus direction in BLT.
Conclusions: Although a BLT yields better lateralization in LSCC canalolithiasis, it may be more useful in predicting the diagnosis and lateralization of PSCC BPPV than LSCC canalolithiasis.
PP1-48 - Vitamin D deficiency and Benign Paroxysmal Positional Vertigo recurrence.
4. Benign Paroxysmal Position Vertigo
Giacinto Asprella Libonati1
Rudi Pecci
2
1 Giovanni Paolo II Hospital, Unit of Vestibology and Otorhinolaryngology, Policoro (MT), Italy Viale Salerno, 75025 Policoro (MT) Italy
2 Azienda Ospedaliero-Universitaria Careggi, Neuromusculoskeletal and Sensory Organs Department, Unit of Audiology, Florence, Italy
Purpose: The study was carried out to verify the effect of supplementation with Vitamin D (VD) or VD + alpha lipoic acid (ALA) on BPPV recurrence.
Methods: From January 2015 to July 2015 we enrolled 125 patients with recurrent BPPV (78 women and 47 men; average age 56 years). All patients underwent physical therapy and venous blood sampling with dosage of VD. Patients with VD deficiency or insufficiency were supplemented with oral VD or VD + ALA. All patients were checked after 3 (T1), 6 (T2) and 12 (T3) months.
Results: All the patients supplemented with only VD, completely compensated their VD deficiency, showing no BPPV recurrence or lower recurrence at T2. Patients showing longer time to recovery VD deficiency (4 patients were still insufficient at T1) had decreased BPPV recurrence at T3. Patients supplemented with VD + ALA, showed lower BPPV recurrence at T2, and no BPPV recurrence or its decrease at T3. All the patients with VD deficiency and still insufficient at T1 (6 patients) had lower BPPV recurrence. All the patients treated adding ALA had no BPPV recurrence at T3, included 6 patients deficient at T0 and insufficient at T1, 4 patients still insufficient at T1 treated with only VD, despite correcting the VD deficit at T2, showed a decreased BPPV recurrence at T3.
Conclusions: VD supplementation reduces the BPPV recurrence in all the treated patients. The addition of alpha lipoic acid, thanks to its antioxidant properties, further improves these results, especially in patients with higher initial deficit (deficiency) and longer recovery time.
PP1-49 - Cogans syndrome: An autoimmune inner ear disease
5. Bilateral Vestibulopathy
Qin Wang
1
1 The Second Xiangya Hospital, Central South University, Department of Otolaryngology Head & Neck Surgery
Purpose: Cogan’s syndrome is a rare disease characterized by coexisting audiovestibular and ocular symptoms. We report a case of clinical manifestation, audiovestibular function, treatment and prognosis of Cogan’s syndrome to have a better understanding of it.
Methods: We describe a case of Cogan’s syndrome in patients with clinical manifestations. The Patient was assessed by Pure tone audiometer, the head impulse protocol and suppression head impulse protocol (HIMPs and SHIMPs), caloric test, vestibular-evoked myogenic potentials (VEMPs) at the initial visit and then then evaluated for symptomatic improvement after 6 months.
Results: The patient had recurrent ocular symptoms for more than ten years, and gradually appeared repeated right knee, right foot pain, accompanied by the collapse nose, ear cartilage bilateral integration, After the emergence of vestibular dysfunction, ears have developed into deafness. The audiovestibular function tests were all abnormal.
Conclusions: Cogan’s syndrome is a rare syndrome with multiple symptoms of ocular symptoms and ear symptoms. The symptoms are not specific and the early diagnosis is difficult. However, the auditory-vestibular system is often poorly predicted and needs to be diagnosed by early diagnosis and treatment.
PP1-50 - Etiology analysis and vestibular assessment of bilateral vestibulopathy
5. Bilateral Vestibulopathy
Ying Lin
1
1 Xijing Hospital, Department of Otolaryngogology Head and Neck Surgery
Purpose: To define clinical and laboratory characteristics of bilateral vestibulopathy (BVP) and to propose diagnostic criteria of this disorder based on clinical and laboratory vestibular function test findings.
Methods: 42 case series with a clinical suspicion of BVP were retrospectively analyzed, in an attempt to determine etiology. Presenting auditory-vestibular symptoms, bedside dynamic visual acuity tests and laboratory test were reviewed, including bithermal caloric test, rotatory chair tests, video head impulse test(vHIT), vestibular-evoked myogenic potentials(VEMP).
Results: Among these 42 patiests, dizziness was seen in 42 case (100%) oscillopsia was seen in 21case (50%) Hearing loss was seen in 30 (71.4%). Eight cases(19%)had tinnitus25 cases showed vestibular loss in dynamic visual acuity test (69.4%). Definite diagnosis of complete BVP was made in 36 patients when the patients showed abnormal findings on caloric test, rotatory chair test and vHIT tests in addition to the symptoms. Whereas probable diagnosis of partial BVP was obtained in 6 patients with abnormal caloric test and rotatory chair test but no pathological vHIT. VEMP(ocular or cervical ) could be recorded in 20 patients. 14 cases were caused by ototoxic drugs while no causes could be determined in 6 cases among these 42 cases.
Conclusions: The diagnosis of BVP is challenging. Vestibular laboratory test battery which reflect full frequency function of VOR has great value to confirming the diagnosis and differentiate definite complete BVP to possible partial BVP. Diagnosis standard shall be made combining clinical history, characteristic symptoms and the results of auditory-vestibular function testing. Ototoxic drugs contribute most considering etiology.
PP1-51 - Frequency properties of postural sway in bilateral vestibulopathy and somatosensory disorder
5. Bilateral Vestibulopathy
Makoto Kinoshita
1
Chisato Fujimoto1, Naoya Egami1, Keiko Sugasawa1, Tatsuya Yamasoba1, Shinichi Iwasaki1
1 University of Tokyo, Department of Otolaryngology and Head and Neck Surgery, Japan
Purpose: To assess the frequency characteristics of postural instability in patients with idiopathic bilateral vestibulopathy (IBV) in comparison with those with somatosensory disorder.
Methods: 36 patients with IBV, 26 patients with somatosensory disorder, and 194 healthy controls were included. In posturography test, two-legged stance tasks were performed in 4 conditions: eyes open with and without foam rubber, and eyes closed with and without foam rubber. We normalized frequency distribution provided by maximum entropy method from 0.01 Hz to 10 Hz every 0.5 Hz about the anterior-posterior and the left-right direction. We defined the “eyes-open-closed difference” as the difference between the normalized values with the eyes closed and that with the eyes open. In addition, we defined the “rubber difference” as the difference between the normalized values with and without foam rubber. We regarded power beyond averages ± 2SD of healthy controls as abnormal.
Results: In IBV patients, postural abnormalities were observed in widespread frequencies in the conditions with eyes closed with and without foam rubber. On the other hand, in patients with somatosensory disorder, those were especially observed above 6Hz in the conditions with eyes closed with and without foam rubber. The abnormality of the rubber difference was characteristic of IBV patients, and the abnormality of the eyes-open-closed difference was characteristic of patients with somatosensory disorder.
Conclusions: The frequency power spectrum analysis of postural stability is useful for the differentiation between IBV and somatosensory disorder.
PP1-52 - Impact of Bilateral Vestibulopathy on Spatial and non-Spatial Cognition: a Systematic Review
5. Bilateral Vestibulopathy
Bieke Dobbels
1
Griet Mertens2, Paul Van de Heyning2, Vincent Van Rompaey2
1 Dept. Otorhinolaryngology & Head and Neck Surgery, Antwerp University Hospital, Belgium. Faculty of Medicine and Health Sciences, University of Antwerp, Belgium
2 1Dept. Otorhinolaryngology & Head and Neck Surgery, Antwerp University Hospital, Belgium. 2Faculty of Medicine and Health Sciences, University of Antwerp, Belgium
Purpose: Growing evidence in animal and human studies suggest that not only hearing loss, but also vestibular loss might result in cognitive deficits. In this review our aim is to evaluate the presence of spatial and non-spatial cognitive deficits in patients with bilateral vestibulopathy (BVP), with and without hearing loss.
Methods: We performed a systematic review according to the PRISMA guidelines on studies considering cognitive performances in BVP patients. Three independent researchers explored Medline and the Cochrane Library. Studies reporting on cognition in BV patients were included according to a predefined eligibility assessment. Data of the patients’ characteristics and their cognitive outcomes were extracted.
Results: Seven studies reporting on 73 BVP patients matched the inclusion criteria. Overall, the methodology of the included papers was of good quality. Criteria for including BVP patients varied widely across studies. Cognitive domains evaluated in patients included visuospatial abilities, memory, language, attention and executive function. Only in one of the seven studies hearing performance of the included patients was briefly described. Nearly all studies demonstrated a significant impairment of spatial cognition in BVP patients. Only recent papers investigated other cognitive domains then spatial cognition. In these papers a negative impact of BVP on the other cognitive domains was also described.
Conclusions: Strong evidence exists that BVP patients suffer from impaired spatial cognition and possibly even general cognitive deficits. However, in all previous studies conclusions on the link between cognitive performance and BVP were drawn without taken hearing loss into consideration as a possible cause of the cognitive impairment.
PP1-53 - Progressive central and peripheral vestibulopathy in superficial siderosis
5. Bilateral Vestibulopathy
Sang Yun Lee1
Dong Han Lee1, Jae-Jin Song1, Yun Jung Bae2, Ji Soo Kim1,
Ja-Won Koo
1
1 Dizziness Center, Seoul National University Bundang Hospital, Korea
2 Department of Radiology, Seoul National University Bundang Hospital, Korea
Purpose: Superficial siderosis (SS) is a rare condition in which hemosiderin, an iron-storage complex, is deposited in neuronal tissues due to recurrent subarachnoid bleeding. Since it is still not clear how the vestibule-cochlear dysfunction and cerebellar ataxia progress, we reviewed the clinical course, patterns of vestibulopathy and progression of cochleovestibular dysfunction over the long term follow-up period, and correlated with radiologic finding in MRI.
Methods: Six patients who diagnosed with SS by magnetic resonance imaging were enrolled. The medical records and radiologic findings of the case series were retrospectively reviewed, particularly, we described the progression of vestibulo-cochlear manifestations and radiologic charicteristics of each case.
Results: All patients showed SNHL. Five out of 6 showed progressive hearing deterioration over years and the progression was asymmetric between ears in 4 patients. Based on the most recent evaluations, four out of six patients showed CA and bilateral vestibulopathy, namely, bilateral combined central- and peripheral vestibulopathy. Remaining two patients demonstrated the bilateral peripheral vestibulopathy, isolated central vestibulopathy, respectively. Hypointensity lesions on T2 weighted images surrounding cerebellum were remarkable in all patients but such lesion surrounding brain stem was not remarkable 1 patients. Though cochlea-vestibular dysfunction was mostly asymmetrically progressed, there was no left-right asymmetry on MRI.
Conclusions: Typically, SS presents bilateral asymmetrically progressive cochleovestibular dysfunction with cerebellar ataxia. Pattern of vestibular dysfunction is most frequently bilateral combined central- and peripheral vestibulopathy. In this perspective, identification of the exact vestibular status and central signs through the regular comprehensive and neurotological evaluations is crucial for treatments and prognosis in SS.
PP1-54 - Are gonadal hormones involved in the pathophysiology of Mal de Debarquement Syndrome?
6. Central Vestibular Disorders
Viviana Mucci
1
Josephine M. Canceri2, Rachael Brown3, Mingjia Dai4, Sergei Yakushin4, Watson Shaun5, Angelique Van Ombergen1, Yves Jacquemyn6, Paul H. Van de Heyning7, Floris Wuyts8, Cherylea J. Browne9
1 Antwerp University Research Centre for Equilibrium and Aerospace/ Department of Gynaecology, Antwerp University Hospital, University of Antwerp. Belgium.
2 School of Science and Health, Western Sydney University, NSW, Australia Western Sydney University , Australia.
3 School of Medicine, Western Sydney University, NSW, Australia Western Sydney University, Australia.
4 Neurology Department, Icahn School of Medicine, Mount Sinai Hospital, NY, United States of America.
5 Department of Neurology, Prince of Wales Private Hospital, NSW, Australia.
6 Department of Gynaecology, Antwerp University Hospital, University of Antwerp, Belgium.
7 Department of Otorhinolaryngology and Head and Neck Surgery, Antwerp University Hospital, University of Antwerp, Belgium.
8 Faculty of Sciences – Lab of Biophysics and Biomedical Physics, University of Antwerp, Belgium.
9 School of Science and Health, Western Sydney University, NSW, Australia Western Sydney University / Translational Neuroscience Facility, School of Medical Sciences, UNSW Sydney, NSW, Australia.
Purpose: Mal de Debarquement Syndrome (MdDS) is a neurological condition which is characterised by a phantom sensation of motion, following exposure to passive motion (e.g. cruise, flight, etc.). This is defined as motion triggered (MT) MdDS. However, it is known that some patients develop typical MdDS symptoms without an apparent motion trigger. This is named spontaneous or other onset (SO) MdDS. For both subtypes, a female predominance has been previously described. The role of gonadal hormones in MdDS pathophysiology has never been investigated. Similarly to what observed in migraine, hormonally regulated mechanism is here hypothesised as a potential contributor to MdDS pathogenesis. Our study aimed to evaluate if MdDS patients report abnormal hormonal profiles and assess possible hormonal influences in the pathophysiology of MdDS.
Methods: This assessment was performed via a retrospective online questionnaire study for both subtypes (MT and SO MdDS).
Results: A total of 370 patients participated in the questionnaires; including 334 females, 25 males and 11 with unspecified gender. Naturally cycling female respondents (from the MT group) reported a significant aggravation of symptoms during ovulation and menstruation.
Conclusions: The results of this study clearly demonstrate a link between hormone fluctuation and symptom aggravation in the MdDS MT group. This provides a strong basis for further hormonal investigation. Our next step is to evaluate hormonal levels through blood sampling, to identify if abnormal hormonal fluctuations or profiles are present in reproductive female patients. We hope this study will help the medical community to broaden their awareness and hormonal knowledge of this condition.
PP1-55 - Central Positional Vertigo
6. Central Vestibular Disorders
Duilio De Schutter
1
Zacharias Adham2, Jorge Kattah2
1 Neurology, Hospital Del Carmen, Mendoza, Argentina
2 University of Illinois College of Medicine at Peoria?, USA.
Purpose: To review the central positional vertigo etiology and diagnosis
Background: Benign paroxymal positional vertigo (BPPV) is the most frequent cause of episodic vertigo. Central positional vertigo and nystagmus (CPV) are also precipitated by positional testing; though infrequent it must be recognized for proper triaging, as it requires an expeditious neurologic work-up. CPV and nystagmus may account for 1% of all causes of vertigo
Methods: Retrospective 16–year analysis of patients with CPV. We excluded all cases with previous history of BPPV and included patients with positional paroxysmal and non-paroxysmal DBN or central horizontal apogeotropic nystagmus examined in two large medical centers in North and South America.
Results: 21 patients with CPV and nystagmus of different etiologies were found. Main diagnosis were: CNS tumor, post-surgical tumor resection and superior canal dehiscense, vascular, infectious, demielinating, familial ataxia, and episodic ataxia syndromes. In one cerebellar glioma positional vertigo was the first manifestation of disease. Positional DBN was largely the most common nystagmus found, followed by horizontal apogeotropic-nystagmus. Nystagmus pattern was decrescendo and no latency was found in the series. Most patients presented other neurological features associated.
Conclusions: Migraine may be a benign cause of CPV, however, a broad spectrum of diseases including tumors, stroke , infections and neurodegenerative disorders may be responsible. Earlier detection of posterior fossa lesions is critical to improve the outcome. Moreover, central positional vertigo could be the very first manifestation of the underlying disease.
PP1-56 - Dissociation between semicircular canals and saccular function in Machado-Joseph Disease
6. Central Vestibular Disorders
Dario Geisinger1
Zohar Elyoseph2, Roy Zaltzman3, Matti Mintz4,
Carlos Gordon
5
1 Tel Aviv University, Sackler Faculty of Medicine, Israel
2 Tel Aviv University, School of Psychological Sciences, Israel
3 Tel Aviv University, Sackler Faculty of Medicine, Meir Medical Center, Department of Neurology, Israel
4 Tel Aviv University, School of Psychological Sciences and Sagol School of Neuroscience, Israel
5 Tel Aviv University, Sackler Faculty of Medicine, Meir Medical Center, Department of Neurology and Sagol School of Neuroscience, Israel
Purpose: Although ocular motor abnormalities are frequent in all forms of Spinocerebellar ataxias (SCAs), vestibulo-ocular reflex (VOR) deficit seems to be a characteristic of SCA-3 (Machado-Joseph disease -MJD). However, all previous studies were focused on lateral semicircular canals function without information regarding the anterior and posterior canal responses and the otolithic function. The aim of this study was to evaluate the three semicircular canals VOR responses and otolithic function in Jew Yemenite patients with MJD in a search for a better neurophysiologic biomarker of the disease.
Methods: Sixteen MJD patients underwent a detailed clinical and laboratory neuro-otological evaluation including horizontal and vertical VOR recordings with the video head impulse test (vHIT) system. Eight of them underwent also cervical vestibular evoked myogenic potentials (cVEMPs) by bilateral tone burst stimulation measuring otolithic saccular function
Results: All MJD patients had significant angular VOR gain decrease (about 50% of normal values) in both horizontal and vertical planes. cVEMPs responses (latency and amplitude of P13 and N23) were normal in all eight examined patients. Ataxia severity evaluated by the Scale for the Assessment and Rating of Ataxia (SARA) was mildly correlated with the degree of VOR impairment.
Conclusions: Angular VOR impairment in horizontal and vertical planes seems to be a distinctive feature of MJD and could be explained by selective rostral vestibular nuclei degeneration. We suggest that quantitative VOR measures could probably be a neurophysiologic biomarker for detecting the appearance and progression of neuro-degeneration in MJD.
PP1-57 - Evaluation of gravitational recognition in patients with spinocerebellar degeneration
6. Central Vestibular Disorders
Takamori Takeda
1
Akihisa Tasaki1, Yuichiro Inaba1, Yusuke Kiyokawa1, Yasuhiro Suzuki1, Takeshi Tsutsumi1
1 Department of Otolaryngology, Tokyo Medical and Dental University, Tokyo, Japan
Purpose: Spinocerebellar degeneration (SCD) is neurodegenerative disorder and demonstrates symptoms with progressive cerebellar ataxia resulting in instability of gravitational recognition. The gravitational recognition associated with SCD has hardly been evaluated and only a limited number of studies exist. We recently develop a method of calculating Listing’s plane obtained from video-oculograms (VOGs), which reflects gravitational recognition constructed through integration of visual, vestibular, and proprioceptive sensory inputs. The purpose of this study is to establish the methods of evaluating gravitational recognition in patients with SCD, using the thickness of the Listing’s plane as a parameter.
Methods: The subjects were wearing infrared CCD-mounted goggles in the sitting and supine position, leaving both eyes unobstructed. 50 cm in front, we placed a screen on which were 9 fixation points. The subjects were instructed to fixate for 1 s on each of the 9 fixation points consecutively. We digitized the video recording using a macro program for ImageJ and calculated thickness of the Listing’s plane on each SCD subjects and healthy controls. In this time, we succeeded to improve the accuracy of measurement, by setting the upper limit of rotational values per frame, to eliminate large rotational artifacts in analyzing data of VOGs.
Results: We identified thickening of Listing’s plane on sitting position in SCD patients than healthy controls, and on sitting position against supine position in SCD patients.
Conclusions: The thickness of Listing’s plane could serve as a parameter which reflects the instability of gravitational recognition in SCD patients.
PP1-58 - Long term observation of slow saccades and caloric response in a SCA2 patient
6. Central Vestibular Disorders
Masakatsu Taki
1
Tatsuhisa Hasegawa2, Yuzuru Ninoyu1, Hirofumi Sakaguchi1, Shigeru Hirano1
1 Department of Otolaryngology - Head and Neck Surgery, Kyoto Prefectural University of Medicine, Japan
2 Department of Otolaryngology, Akashi City Hospital, Japan
Purpose: To follow up long term of slow saccades and caloric responses in a patient with spinocerebellar ataxia type2 (SCA2)
Methods: The subject was a male patient with SCA2. At age of 32 years old, he was referred to the Department of Otolaryngology - Head and Neck Surgery, Kyoto Prefectural University of Medicine for the evaluation of eye movements and vestibular function. Saccadic, and smooth pursuit eye movements and caloric stimuation were examined. Saccadic eye movements were also examined at the angles of 10, 20, 30, 60 and 90 degrees. To calculate main sequence of saccadic eye movements, maximum velocities were plotted against amplitudes and were exponentially fitted as follows: Vmax = k x (1-exp(-amp/tau)). Eye movements were measured with electronystagmugraphy. We compared saccadic, and smooth pursuit eye movements and maximum slow phase velocity of caloric nsytagmus every year.
Results: Slow saccades were observed from one year later (first examination) to five years later. Six years later, tremor was superimposed. Eight years later, he could not pursuit target. Smooth pursuit eye movements were normal until five years later. However, maximum slow phase velocity of caloric nystagmus fluctuated depending on years. The coefficient k also increased and decreased as caloric responses changed by year. k was 93.6, 212.9, 249.3, 194.8 for three, four, five ,six years later, respectively. In normal subject, k was 824.9.
Conclusions: These results suggest that slow saccades may not monotonically be aggravated by year. In this case, rehabilitation probably improved the saccadic eye movements but only for several years.
PP1-59 - Metabolic and Visuospatial Memory Function Changes in Transient Mal de Debarquement Syndrome
6. Central Vestibular Disorders
Seung-ho Jeon
1
Ko woon Kim1, Hyun-June Shin1, YEON-HEE HAN2, HWAN-JEONG JEONG2, Sun-Young Oh1
1 Department of Neurology, Chonbuk National University Medical School and Hospital, Jeonju, Korea
2 Department of Nuclear Medicine, Chonbuk National University Medical School and Hospital, Jeonju, Korea
Purpose: Mal de debarquement syndrome (MdDS) is a subjective perception of self-motion after a period of travel, classically by boat. It is not commonly encountered in clinical practice, but an enigmatic neurotological disorder with high morbidity. The pathogenesis of MdDS is not well-understood and therefore, treatment options are limited.
Methods: We studied 29 subjects who were fishermen at Buan, including 16 subjects (6 males) who had transient MdDS (t-MdDS) or land sickness (less than 12 hours of symptoms after boating) and 13 subjects who do not have symptoms. They were undertaken a neurotological examination, vestibular function tests and visuospatial function tests including Corsi block task. Brain MRI and 18F-FDG brain PET were also performed.
Results: Vestibular functions were within normal range and structural brain lesion was not detected in any subjects. However, the Corsi block test was scored as a mean of 6.40 in t-MdDS subjects and 5.31 in the control group (p=0.016). 18F-FDG brain PET imaging revealed increased glucose metabolism in the primary visual cortex, prefrontal and inferior parietal lobules bilaterally in the setting of decreased inferior cerebellum metabolism in subjects with transient MdDS.
Conclusions: Our results show that the patients of t-MdDS revealed better performance of visuospatial memory task and hypermetabolism in neural systems involving visual spatial working memory with hypometabolism in cerebellum. These findings indicate that MdDS maybe a disorder of over-synchronization of visuospatial memory networks caused by persistent background low-amplitude oscillating environments coupled with an inability to subsequently desynchronize the activity of these networks reflected by hypometabolism in the cerebellum.
PP1-60 - Nystgamus and vestibular loss in autoimmune and paraneoplastic ataxia syndromes
6. Central Vestibular Disorders
Jorge Kattah
1
Ali Saber Tehrani2, Diana Londono3, Xiaojun Zhang4
1 University of Illinois College of Medicine . Peoria, IL
2 University of Illinois College of Medicne. Peoria, IL
3 University of Illinois College of Medicine. Peoria, Il
4 University of Illinois College of Medicine. Peoria,IL
Purpose: To investigate oculomotor and vestibular evaluation results and to correlate them with immuno-phenotypes in autoimmune ataxia (AA).
Methods: Retrospective neurotologic chart reviews of adult AA patients examined from 2001-2016. None of the patients had a history of familial ataxia (FA)
Results: 13 patients met the diagnostic criteria of AA, 12 had one specific antibody that was presumably the cause of the ataxia. The initial MRI of the brain was normal in all instances. Six patient had an anti-Gad antibody, two had ant-Yo, two anti-Hu and two had miscellaneous antibodies. Seven had the ataxia as the first symptom of cancer and two had previous cancer in remission. One had a previous thymoma resection. The remaining four cases were autoimmune. One had RA and other Chron’s disease. The most common primary gaze nystagmus was downbeat (DBN) in n= six, one had Opsoclonus and the remaining had gaze evoked nystagmus (GEN) and abnormal pursuit. Three patients had bilateral, symmetric vestibular paresis. Six patient had a lymphocytic meningitis, the CSF was normal in the anti-GAD antibody patients.
Conclusions: A syndrome characterized by acute or subacute ataxia and imbalance associated with a normal MRI and no history of FA, suggests AA. The ant-GAD antibody syndrome was less frequently associated with cancer than other autoantibodies; common findings included DBN, GEN, impaired pursuit, bilateral vestibular paresis and Opsoclonus. Rapid initiation of immunosuppression, plasma exchange and search for an occult cancer are the first step in management. The anti-Gad antibody syndrome has better prognosis even if cancer is present.
PP1-61 - Positional tests under Videonistagmography for Central Positional Vertigo Diagnosis
6. Central Vestibular Disorders
Fernanda Vidigal Vilela Lima
1
Claudia Marques Dias1
1 Hospital Madre Teresa
Purpose: Positional vertigo is vertigo triggered by and occuring after a change of head position in space realtive to gravity.
Central vestibular disorders are caused by lesions along the vestibular pathways in the brainstem. It can manifest the same symptoms than peripheral disorders. The clinical examination of eye movements and of nystagmus is important for differential diagnostics. The positional test under Videonistagmography can be very helpful, specially for the patients that didn’t present any abnormality in MRI.
Methods: This study selected patients that had positional vertigo and were evaluated under Videonistagmography. They didn’t fulfilled the diagnostic criteria for vestibular migraine, presented nystagmus that dind’t fulfilled the criteria for peripheral disorders and had normal MRI. Eye movements were recorded in darkness in the following positions: sitting with head upright, sitting with chin to chest position, lying, lying with the left and right ear down. Oculomotor test were also taken.
Results: Seventeen patients with positional vertigo were evaluated under VNG and presentes abnormal nystagmus with central characteristics during the exam. Two patients were male and fifteen were female. The mean age was sixty five years. Fourteen patients had their nystagmus inverted after head postion changes.
Conclusions: The Videonistagmography positional test allows an easily evaluation of nystagmus and play a decisive role in the diagnosis of Central Positional Vertigo. It can give an effective mesure for diagnose and follow-up in these patients.
PP1-62 - Subjective visual vertical in typical Alzheimer’s disease and posterior cortical atrophy
6. Central Vestibular Disorders
Dilek Ocal1
Amy Peters2, Matthew Bancroft2,
Diego Kaski2, Chris Lane1, Thomas Parker1, Aida Suarez Gonzalez1, Ivanna Pavisic1, Jessica Collins1, Natalie Ryan1, John Schott1, Nick Fox1, Keir Yong1, Brian Day2, Sebastian Crutch1
1 Dementia Research Centre, Department of Neurodegeneration, UCL Institute of Neurology, University College London, London, UK
2 Sobell Department of Motor Neuroscience and Movement Disorders, University College London, London, UK
Purpose: The parietal lobes, an area fundamental for integrating multimodal sensory input, have been implicated in the misperception of verticality, suggesting a possible link between damage in this area and inappropriate internal representation of verticality which has been associated with imbalance. The current project investigated perception of verticality in posterior cortical atrophy (PCA) and typical Alzheimer’s disease (tAD) under varying visual cue conditions using the Rod-and-Frame task.
Methods: Twenty PCA, 16 tAD and 13 healthy control participants performed the ‘rod and frame’ test, where they were asked to align an oblique white rod presented on a screen with the perceived vertical while seated (24 trials). The Rod was presented at 45° tilt with or without the presence of a visual cue (square frame) which was randomly presented under two tilt conditions (18° left/right). Task performance measures included orientation error between perceived and absolute vertical.
Results: In the absence of visual cues, orientation error was greater in PCA relative to tAD and control groups; there was no evidence of an overall difference between tAD and control groups. Visual cues exerted greater influence upon the perception of verticality in both PCA and tAD relative to control groups, with cue orientation inducing particular bias in patient responses. We observed lateralized effects of visual cues in PCA, but not tAD or control groups.
Conclusions: Findings support erroneous internal representation of verticality in both PCA and tAD, but also suggest differences between clinical phenotypes. Results are interpreted in the context of differences in structural imaging profiles.
PP1-63 - The Semicircular Canal Coordinate System and Its Relation to Neural Circuits for Saccades
6. Central Vestibular Disorders
Mayu Takahashi
1
Yuriko Sugiuchi1, Yoshikazu Shinoda1
1 Tokyo Medical and Dental University, Dept. of Systems Neurophysiology, Japan
Purpose: It is generally accepted the saccadic system uses horizontal and vertical Cartesian coordinate system. Brainstem centers for horizontal and vertical saccades were identified in the PPRF and the riMLF, respectively. However, the neural pathways from the superior colliculus (SC) to ocular motoneurons (MNs) via these lower centers had not been understood well.
Methods: We analyzed output pathways for horizontal and vertical saccades by using intracellular recording and HRP-staining methods in anesthetized cats.
Results: The shortest excitatory and inhibitory pathways from the SC to abducens MNs were tacitly assumed trisynaptic and quadrisynaptic, respectively, but the main shortest pathways were disynaptic: excitation in contra-abd MNs via excitatory burst neurons (EBNs) and inhibition in ipsi-abd MNs via contra-inhibitory BNs (IBNs). All vertical MNs received disynaptic excitation from ipsi-SC via EBNs in ipsi-riMLF, and disynaptic inhibition from contra-SC via IBNs in contra-interstitial nucleus of Cajal. The medial and lateral SC representing upward and downward saccades innervated superior rectus and inferior oblique MNs, and inferior rectus and superior oblique MNs, respectively, and strong reciprocal commissural inhibition existed between the medial and lateral SCs.
Conclusions: These innervation patterns are similar to those in vertical VOR, where the anterior canal system on one side inhibits via vestibulo-nuclear commissural inhibition the posterior canal system on the opposite, and vice versa. There was also reciprocal inhibition between the upward saccade system on one side and the downward saccade system on the opposite side. This similarity of reciprocal inhibition implies that the saccade system uses the same semicircular canal coordinate as the VOR.
PP1-64 - Tumor size of vestibular schwannoma impair vestibular function and compensation
6. Central Vestibular Disorders
Jing Wang
1
1 Department of Otology and Skull Base Surgery, Eye Ear Nose and Throat Hospital, Fudan University, 83 Fenyang Road, Shanghai, China
Purpose: To investigate the relationship between vestibular schwannoma (VS) size and the dysfunction and compensation of the vestibular system.
Methods: A total of 152 patients with unilateral VS were investigated by auditory-vestibular function tests such as audiometry, sensory organization test (SOT), caloric test, cervical and ocular vestibular evoked myogenic potential (cVEMP and oVEMP) tests.
Results: In this study, 89% patients with unilateral VS had mild to severe hearing loss. Lower waveform elicited rates and higher thresholds in both cVEMP and oVEMP tests had been found in affected sides of patients, compared with the unaffected sides. Patients with tumor size ≥ 30 mm showed significantly lower equilibrium scores of C5 and C6 in SOT test, higher rates of canal paresis and lower waveform elicited rates in cVEMP and oVEMP tests in the affected sides compared with the patients with tumor size ≤29 mm.
Conclusions: There was no significant relationship between tumor size and hearing loss level. Patients with large VS might be more prone to vestibular dysfunction and showed decompensation with poor postural performance.
PP1-65 - Use of proprioception differentiates postural control in peripheral and central vestibular patients
6. Central Vestibular Disorders
Isabella Katharina Wiesmeier
1
Emmanuel Tagoe1, Joost van Kordelaar2, Christoph Maurer1
1 University Medical Center Freiburg, Department of Neurology and Neurophysiology, Germany
2 University of Twente, Department of Biomechanical Engineering, Enschede, The Netherlands
Purpose: Imbalance is an accompanying symptom of vertigo but may vary between central and peripheral origin. As this differentiation has a tremendous clinical impact, but often is difficult to achieve, the systematic identification of the postural control process may add to this distinction.
Methods: Unperturbed and perturbed stance of patients with a central (Vsc, n=7), or a peripheral vestibular deficit (Vsp, n=14) and 15 healthy control subjects (Np) were examined on a custom-built motion platform. Data was analyzed using transfer functions (Gain, Phase, and Coherence) of motor responses, followed by a parameter identification procedure.
Results: Sway amplitude (RMS) and velocity (MV) were significantly higher in Vsp, compared to Np and Vsc. Transfer functions were different in Vsp, Vsc and Np. Vsc patients relied more on proprioception, compared to NP with both eyes open and eyes closed, whereas Vsp patients showed an increased reliance on proprioception only with eyes closed. Moreover, Vsp displayed an overall larger time delay between stimulus and response, as compared to Np and Vsc.
Conclusions: Postural control of patients with a peripheral vestibular deficit is different from patients with a central vestibular deficit during both unperturbed and perturbed stance. Characteristic features relate to the role of proprioception when comparing the eyes open and eyes closed-condition as well as the role of the time delay between stimulus and response. These postural abnormalities may help to distinguish peripheral from central vestibular deficits.
PP1-66 - Vestibular dysfunction in Wernickes encephalopathy: selective impairment of the horizontal canals
6. Central Vestibular Disorders
Seung-Han Lee
1
Sang-Hoon Kim1, Ji-Min Kim1, Alexander Tarnutzer2
1 Chonnam National University Medical School and Hospital, Department of Neurology, South Korea
2 University Hospital Zurich and University of Zurich, Department of Neurology, Switzerland
Purpose: To better characterize the pattern of vestibular impairment in patients with Wernicke’s encephalopathy (WE) using quantitative video head-impulse testing and to review the literature regarding this topic.
Methods: From January 2014 to December 2016, we retrospectively enrolled five cases of WE that received quantitative video-head-impulse testing. We retrieved the clinical features from the medical records and reviewed quantitative head-impulse testing and caloric irrigation. Based on the gain and the number of corrective saccades, the function of each semicircular canal was rated. In addition, we conducted a Medline and EMBASE search to identify other published cases of WE that had received quantitative head-impulse testing. Neuro-otologic findings and vestibular-testing results were extracted.
Results: A total of 17 patients (12 published cases) were included. Key neurologic findings were ataxia of stance and gait (100%), spontaneous nystagmus (50%), gaze-evoked nystagmus (100%), positive bedside head-impulse testing for the horizontal canals (94%) and memory impairment and mental changes (54.5%). Regarding vestibular testing, quantitative head-impulse testing documented selective bilateral horizontal canal dysfunction with normal or minimal vertical canal impairment (100%). On caloric irrigation, bilateral horizontal canal paresis was noted in most cases (91%).
Conclusions: In WE, signs of both peripheral and central vestibular dysfunction were common. Selective or predominant impairment of the horizontal canals seems to be a characteristic finding of WE likely related to enhanced vulnerability of the medial vestibular nuclei neurons to thiamine deficiency. Quantitative video-head-impulse testing of all six canals is a useful tool for the diagnosis and should be applied in all patients with suspected WE.
PP1-67 - Visual fixation suppression of caloric nystagmus in progressive supranuclear palsy
6. Central Vestibular Disorders
Rie Naito
1
Yuki Watanabe1, Akira Naito1, Keiko Sugasawa1, Yasuhiro Nakata2, Tutomu Kamiyama3, Ryouichi Okiyama3, Fusako Yokochi3, Eiji Isozaki3, Tatsuya Yamasoba4
1 Tokyo Metropolitan Neurological Hospital, Department of Neuro-Otology, Japan
2 Tokyo Metropolitan Neurological Hospital, Department of Neuro-Radiology, Japan
3 Tokyo Metropolitan Neurological Hospital, Department of Neurology, Japan
4 The University of Tokyo, Department of Otorhinolaryngology, Japan
Purpose: Progressive supranuclear palsy (PSP) is a degenerative disease of the basal ganglia, characterized by decreased muscle tone, postural instability, and abnormal eye movements. However, impaired visual fixation suppression (VS) in PSP is not well documented in the literature. We investigated visual fixation suppression (VS) of caloric nystagmus and radiological findings in PSP.
Methods: Subjects comprised 26 patients (14 males, 12 females) without horizontal gaze palsy, diagnosed in the Department of Neurology at Tokyo Metropolitan Neurological Hospital. As a control group, 26 patients (11 males, 15 females) with Parkinson disease (PD) also diagnosed in the Department of Neurology at our hospital were investigated. We retrospectively investigated neuro-otological findings, including VS of caloric nystagmus recorded on DC electronystagmography, and radiological findings such as brain magnetic resonance imaging (MRI) and single photon emission computed tomography (SPECT) for patients with PSP and PD.
Results: VS of caloric nystagmus was remarkably impaired in PSP compared to that in PD. Brain MRI showed atrophy of the superior colliculi in all 26 cases of PSP, of the cerebellum in 4 of 26 PSP, and of the subthalamic nucleus in 15 of 25 PSP. In contrast, PD patients did not exhibit any significant findings on MRI. SPECT revealed decreased blood flow in the frontal lobe in 20 of 22 PSP, and in 11 of 22 PD patients.
Conclusions: VS would be very useful for PSP diagnosis. Cerebellar networks with the cerebral cortex and basal ganglia might contribute to impaired VS of caloric nystagmus in PSP.
PP1-68 - 3D analysis of VOR and spatial orientation during eccentric rotation while right ear downwards
7. Clinical Testing for Vestibular Function
Takao Imai
1
Xiuwen Jiang2, Tomoko Okumura1, Yumi Ohta1, Yasuhiro Osaki1, Takashi Sato1, Yoshiyuki Ozono1, Ryusuke Imai1, Yukiko Hanada1, Ryouhei Oya1, Hidenori Inohara1
1 Osaka University Graduate School of Medicine, Otorhinolaryngology - Head and Neck Surgery, Japan
2 Medical College of Zhejiang University, Otorhinolaryngology - Head and Neck Surgery, China
Purpose: To develop the functional test of saccule by analyzing vertical component of vetibulo-ocular reflex (VOR) during eccentric rotation (ER). When ER, subjects were rotated sinusoidally while displaced from the axis of rotation. And we analyzed the relationship between the VOR and the spatial orientation.
Methods: Ten participants underwent sinusoidal ER at 0.1, 0.3, 0.5, and 0.7 Hz while right ear downwards in a dark room. The participants sat on the chair either directly above the center of rotation (CR), or with their nose out (NO-ER), nose in (NI-ER), right-side out (RO-ER), or left-side out (LO-ER) against the center of rotation. The radius of rotation was 90 cm. We analyzed linear VOR (lVOR) three-dimensionally using our own video-oculography system. Every participants were instructed to report their sitting position before and after each rotation in order to evaluate their spatial orientation.
Results: At 0.1 and 0.3 Hz rotation, we observed the VOR gain during NI-ER was lower, and that during NO-ER was higher at 0.5 and 0.7 Hz than during CR. These results indicated that lVOR played a role at 0.5 and 0.7 Hz during ER and the opposite direction of lVOR resulted in the increment and decrement of VOR gain during NO-ER and NI-ER respectively. The accuracy of spatial orientation was higher in 0.5 and 0.7 Hz than that in 0.1 and 0.3 Hz.
Conclusions: The function of saccule can be assessed via rotation test of NO-ER and NI-ER. The spatial orientation is related to frequency, and is governed by lVOR.
PP1-69 - A normative study of the Dynamic Visual Acuity test, with comparison of two vertical test methods
7. Clinical Testing for Vestibular Function
Sandrien Mertens
1
Thomas Tubbax2, Liesbeth Smets2, Catherine Blaivie1, Robby Vanspauwen1
1 ENT Department, Sint-Augustinus Hospital Antwerp, European Institute for ORL-HNS, Belgium
2 Thomas More College Antwerp’
Purpose: The purpose of this study was to obtain normative test-retest data of the Dynamic Visual Acuity test and to compare two vertical DVA test protocols (vertical head movement vs. walking on treadmill).
Methods: 31 healthy subjects (15 women, 16 men) between 18 and 31 years were tested and retested on different test days. Static Visual Acuity (SVA) test was done, followed by horizontal DVA (hDVA) testing (active head rotations around the yaw-axis) at four different frequencies: 0.7, 1.0, 1.4 and 2.0 Hz. Vertical DVA (vDVA) testing was done in 2 ways: firstly, by active pitch head movements (0.7, 1.0, 1.4 and 2.0Hz) and secondly by walking on a treadmill at walking speeds of 2, 4 and 6 km/h. For each test modality, a logMAR score was calculated as the smallest recognized optotype.
Results: There were no significant test-retest differences, besides for SVA testing (p=0.009, logMAR test = -0.0230 (±0.077); logMAR retest = -0.273 (±0.020)). There was no significant difference between the following test frequencies: 0.7 Hz vs 1.0 Hz and between 1.0 and 1.4 Hz, for both hDVA and vDVA. There were no significant vDVA differences between the logMAR scores of all walking velocities on the treadmill. Correlation between vDVA obtained on the treadmill and with active head movements was weak (R2 = 27.4%).
Conclusions: Except for SVA, we found no significant differences between test and retest values, indicating that our test protocol is reliable. The clinical significance of the abovementioned results will be analysed further in vestibular patients.
PP1-70 - Analysis of the result of normal youth sinusoidal harmonic acceleration test by NKI rotation chair
7. Clinical Testing for Vestibular Function
Li Shanshan
1
chen taisheng1, lin peng1, liu qiang1
1 Tianjin first center hospital, Otolaryngology Head and Neck surgery, China
Purpose: Frequency doubling is used in the previous sinusoidal harmonic acceleration test. However, the frequency doubling test is too large in the high frequency area to show the vestibular function. We test more frequency of the sinusoidal harmonic acceleration test by the NKI rotation chair, aimed to analysis the result of the normal youth.
Methods: Fifty normal young people were tested with sinusoidal harmonic acceleration by NKI rotation chair. Age from 20 to 40 years (Median age27), there 24 men, and 26 women, with no vestibular dysfunction participated in this study. All the volunteers accept the sinusoidal harmonic acceleration test by the NKI rotation chair, the frequency include 0.01Hz, 0.02Hz, 0.03Hz, 0.05Hz, 0.1Hz, 0.2Hz, 0.3Hz, 0.6Hz, 1.0Hz, 1.5Hz, 2.0Hz, 3.0Hz. The gain, phase and asymmetric values are analyzed as parameters.
Results: The gain in the different frequency were 0.01Hz (0.30 ± .082), 0.02Hz (0.40 ± 0.09), 0.03Hz (0.47 ± 0.10), 0.05Hz (0.51 ± 0.13), 0.1Hz (0.53 ± 0.15), 0.2Hz (0.55 ± 0.15), 0.3Hz (0.59 ± 0.18), 0.6Hz (0.63 ± 0.19), 1.0Hz (0.83 ± 0.13), 1.5Hz (0.95 ± 0.12), 2.0Hz (0.85 ± 0.20), 3.0Hz (0.71 ± 0.32).The phase in the different frequency were 0.01Hz (44.97 ± 7.72), 0.02Hz (25.83 ± 5.25), 0.03Hz (17.20 ± 5.20), 0.05Hz (9.19 ± 3.27), 0.1Hz (2.84 ± 2.79), 0.2Hz (0.42 ± 3.52), 0.3Hz (0.88 ± 2.93), 0.6Hz (0.54 ± 4.79), 1.0Hz (-0.38 ± 4.28), 1.5Hz (-3.87 ± 5.00), 2.0Hz (-13.91 ± 10.59), 3.0Hz (-27.84 ± 52.91).The asymmetry in the frequency were 0.01Hz (16.39 ± 9.84), 0.02Hz (18.08 ± 8.44), 03Hz (12.85 ± 8.64), 0.05Hz (9.36 ± 7.88), 0.1Hz (5.91 ± 7.73), 0.2Hz (5.81 ± 6.26), 0.3Hz (5.07 ± 6.17), 0.6Hz (3.70 ± 3.51), 1.0Hz (1.77 ± 2.74), 1.5Hz (-0.28 ± 3.60), 2.0Hz (-2.50 ± 11.81), 3.0Hz (-7.56 ± 1.19).
Conclusions: From 0.01Hz to 1.5Hz, the gain increases close to 1 gradually. And with a slight drop at the 2.0Hz, 3.0Hz frequency. The phase decrease as frequencies increased. The asymmetry from 0.01Hz to 3.0Hz is gradually approaching to 0, and present negative values in the frequency 1.5Hz, 2.0Hz, 3.0Hz. It is important to make sure that the head of the patient is well fixed in the high frequency test.
PP1-71 - Anxiety, depression, and visual dependence assessment in neuro-vestibular physical therapy
7. Clinical Testing for Vestibular Function
Brooke N. Klatt
1
Patrick J. Sparto1, Carrie W. Hoppes2, Kathleen Brandfass1, Susan L. Whitney1
1 University of Pittsburgh, Department of Physical Therapy, United States of America
2 Army-Baylor University, Department of Physical Therapy, United States of America
Purpose: Anxiety, depression, and visual dependence (ADVD) are associated with less than optimal functional outcomes for people with vestibular disorders. The aim of this study was to determine if ADVD are being assessed in outpatient neuro-vestibular physical therapy and if the methods used for assessment are standardized.
Methods: Thirty-two outpatient physical therapists (PT’s) identified as primarily treating people with neurologic and vestibular diagnoses were invited to complete an electronic survey about the assessment and treatment of ADVD.
Results: Survey completion rate was 53%. Twenty-nine percent of the therapists “always” assess for anxiety (35% “most of time”; 6% “half the time”; 24% “sometimes”; and 6% “never”). Depression assessment ratings were similar. The PT’s reported that assessments of anxiety and depression were gathered during patient interviews (88%) and from the medical record (94%).
Visual dependence was assessed slightly more frequently by the PTs (57% “always”; 38% “most of time”; 5% “half the time”). Eight different methods were reported and six of the eight methods were not measures of visual dependence. The most common methods reported to assess visual dependence were the modified Clinical Test of Sensory Interaction and Balance (67%), Romberg (43%), and Computerized Dynamic Posturography (33%).
Conclusions: Only 50% of the PT’s are attempting to assess anxiety, depression or visual dependence in persons seen with vestibular disorders and when they do assess the patients the methods used are often not optimal to clinically assess the construct.
PP1-72 - Balance and Eye Movement Responses to Electrical Vestibular stimulation in Vestibular Schwannoma
7. Clinical Testing for Vestibular Function
Stuart Mackenzie
1
Richard Irving2, Peter Monksfield2, Raghu Kumar2, Attila Dezso2, Raymond Reynolds1
1 University of Birmingham, School of Sport, Exercise & Rehabilitation Sciences, UK.
2 University Hospital Birmingham, Centre for Rare Diseases, UK.
Purpose: Many patients are unable to perform postural tests due to instability and the inherent variability of caloric irrigation suggests a new technique is required. We examine the viability of electrical vestibular stimulation (EVS) to detect vestibular dysfunction in vestibular schwannoma patients (VS), who have a known unilateral deficiency.
Methods: EVS induces a sense of head roll around the naso-occipital axis, evoking compensatory torsional eye movements. Here we aim to determine if this technique can detect asymmetry between ears. Participants received sinusoidal EVS (2hz,±2mA) in a monaural configuration. An infrared camera and illuminator were used to record torsional eye movements. The response-EVS gain was calculated for each and an asymmetry ratio (AR) was determined.
Results: We found there to a be a difference in the gain of the response between healthy and diseased ears (AR:10-50%), with the diseased ear’s response being significantly attenuated (T(24)=3.04,p<0.05). When participants were grouped according to tumour size, using Koos classification system, we found larger tumours resulted in smaller torsional responses leading to a greater asymmetry.
Conclusions: These results provide a novel method of assessing vestibular function in a population where normal postural tests are unsuitable due to some participants, inability to remain upright during the test. The relationship between tumour size and response can potentially provide additional information regarding tumour size and potentially location. The information provided about vestibular function can be considered when planning an appropriately course of treatment for the participant (i.e. balance therapy may be advised for those with significant vestibular loss).
PP1-73 - Can HIT and oVEMP evaluate the superior vestibular nerve function in substitution for caloric test?
7. Clinical Testing for Vestibular Function
Ko Shiraishi
1
Takaaki Kobayashi1, Takeshi Huzita1, Toru Seo1, Katsumi Doi1
1 KINDAI University/Otolaryngology/Japan
Purpose: Although caloric test and video head impulse test (vHIT) reflect function of the lateral semi-circular canal ampulla, the former relate to the type 2 hair cell and regular neuron and the later relate to type 1 hair cell and irregular neuron. Ocular vestibular evoked myogenic potential (oVEMP) reflects function of the utricular organ. While all the afferent pathways are superior vestibular nerve, the sensory receptors and afferent neuron differ, This study aims to clarify whether the examinations can substitute for each other in evaluating the nerve function.
Methods: Subjects were seventeen patients diagnosed with vestibular schwannoma in MRI scans and underwent caloric test, vHIT and oVEMP. The positive results of each examination was evaluated. The cut-off criteria as abnormal in each examination were as follows: 1) CP> 25% in caloric test, 2) VOR gain <0.88 in vHIT, 3) AR> 31.6% in oVEMP. Predictive ability from caloric test was analyzed with ROC.
Results: Positive rate was 59% in caloric test, 53% in vHIT and 69% in oVEMP. The sensitivity, specificity and AUC of ROC analyze were 0.88, 0.91 and 0.87 on the result of vHIT, respectively and 0.80, 1.00 and 0.90 on the results of oVEMP, respectively.
Conclusions: Due to the difference of the sensory receptor and afferent neuron, we had speculated that there might be differences in the results of the three tests, however, there was no statistical difference. The caloric test can be replaced with vHIT or oVEMP in the patients with vestibular schwanoma.
PP1-74 - Cervico-Ocular Reflex Induced by Manual stimulus of the Sternocleidomastoid Muscle: The First Report
7. Clinical Testing for Vestibular Function
Yuichiro Inaba
1
Chiaki Hirai1, Takamori Takeda1, Akihisa Tasaki1, Yusuke Kiyokawa1, Yasuhiro Suzuki1, Takeshi Tsutsumi1
1 Department of Otorhinolaryngology, Tokyo Medical and Dental University, Japan
Purpose: To describe a novel afferent pathway for the cervico-ocular reflex (COR), as the first report of detecting COR without use of a rotational chair.
Methods: A patient with complete right canal paralysis and incomplete left canal paralysis, caused by aseptic meningitis, was examined through manual stimulation by compressing or grasping each sternocleidomastoid muscle (SCM) in turn. Vibrational stimulation was also applied to each side of SCM and mastoid process of this patient to differ this nystagmus from previously reported vibration induced nystagmus (VIN). Electronystagmography recordings were assessed under this manual stimulation and vibrational stimulation.
Results: Nystagmus similar to previously reported COR was observed with above mentioned manual stimulation of the SCM, which directed toward the stimulated side. However, due to conductive diffusion, the direction of VIN was not affected by stimulated side. In this case, VIN was consistently directed toward the left side, on which canal paralysis was incomplete.
Conclusions: COR is one of the visual stabilizing eye movement like the vestibulo-ocular reflex and optokinetic reflex, elicited by passive rotation of the neck. It has widely been considered to be generated only by the cues from the facet joints of cervical spine and the dorsal neck muscles. This case provides the evidence that cues from SCM also generate COR.
PP1-75 - Clinical features of otolith organ-specific vestibular dysfunction
7. Clinical Testing for Vestibular Function
Chisato Fujimoto
1
Sayaka Suzuki2, Makoto Kinoshita2, Naoya Egami2, Keiko Sugasawa2, Shinichi Iwasaki2
1 Department of Otolaryngology, Tokyo Teishin Hospital, Japan
2 Department of Otolaryngology and Head and Neck Surgery, Graduate School of Medicine, The University of Tokyo, Japan
Purpose: To elucidate the clinical features and vestibular symptoms of patients with otolith organ dysfunction in the presence of normal function of the semicircular canals (SCCs).
Methods: We reviewed the clinical records of 277 consecutive new patients with balance disorders who underwent testing of cervical and ocular vestibular evoked myogenic potentials (cVEMPs and oVEMPs) as well as caloric testing and video head impulse testing (vHIT).
Results: We identified 76 patients who showed normal caloric responses and normal vHIT findings in each SCC plane, but abnormal responses in cVEMP and/or oVEMP testing. Benign paroxysmal positional vertigo (BPPV) was the most common diagnosis. 37% of patients could not be categorized into any of the established clinical entities that could cause a balance disorder and did not show sensorineural hearing loss. The most common clinical manifestation in the idiopathic cases was recurrent rotatory vertigo with a duration of 1–12 h.
Conclusions: The most common diagnosis of otolith organ-specific vestibular dysfunction was BPPV. On the other hand, otolith organ-specific vestibular dysfunction occurs in association with some of the undiagnosed patients with recurrent rotatory vertigo.
PP1-76 - Clinical study of the new three dimensional rotating equipment in vestibular function detection
7. Clinical Testing for Vestibular Function
Zhan-guo Jin
1
Jian-chang Wang1, Xian-rong Xu1
1 General Hospital of Air Force, Aerospace Balance Medical Center, Beijing, China
Purpose: To explore the effectiveness of new vestibular function detection, correction and training equipment for healthy person’s vestibular function.
Methods: 35 healthy persons in the equipment in the dark field were stimulated by rotation with the spindle rotating 1570° while the auxiliary axis rotating 1565° of the 3D rotation stimulus. The difference was compared between the residual angle of gravity, the residual angle of the horizontal plane and the time of the third active adjustment after three rotations and to monitor the change of blood pressure before and after rotation.
Results: There was no significant difference between the residual angle of gravity (6.04±10.70°, 3.57±3.97°, 3.41±2.93°, P=0.199), however, The residual angle of the horizontal plane is statistically significant94.930±58.826°, 66.736±45.989°, 65.494±47.989°, P=0.028<0.05. There was no difference in active adjustment time after three rotations190.114±87.328s, 178.014±110.811s, 173.743±87.332s, P=0.760, and there was no significant difference in the systolic and diastolic blood pressure before and after the three rotations.
Conclusions: The new vestibular function detection, correction and training equipment is a three-dimensional rotating instrument that can detect three pairs of semicircular canal, two pairs of otolithic organ function, including benign paroxysmal positional vertigo, semicircular canal function correction and rehabilitation training, and quantitative detection of the function of oval sac, saccule and rehabilitation training, according to the results of the study found that adaptive training of the saccule is effective. Therefore, the research group will gradually carry out the controlled study of vestibular related disease detection, correction and training, expand and deepen the real use of research equipment.
PP1-77 - Clinical usefulness of dizziness diagnosis in the foam posturography analysis system
7. Clinical Testing for Vestibular Function
Noriko Nagai
1
Yusuke Shoji1, Naiue Kikawada1, Sachie Kawaguchi2, Yasuo Ogawa3
1 Kohsei Chuo General Hospital
2 Yokohama asahi chuo general hospital
3 Tokyo Medical University Hachioji Medical Center
Purpose: The foam posturography analysis system is useful to detect the peripheral vestibulopathy and can easily screen for it. The foam posturography by company Anima has evaluations of the four level, Aa(most likely to have vestibulopathy), Ab(likely), B(possibly), C(unlikely) which is based on the romberg’s ratio under the foam rubber and the foam ratios (ratios of measured parameter with to without the foam rubber).The purpose of this study is to assess the clinical utility by comparing clinical diagnosis and the results.
Methods: We divided into two groups, vestibulopathy group and non vestibulopathy group. The clinical diagnosis and the results in the foam posturography analysis system were reviewed.
Results: Ninety three patients diagnosed clinically out of 117 patients who underwent the test were enrolled this study. We compared the vestibulopathy group and the non vestibulopathy group. The vestibulopathy group were 61 patients. Non vestibulopathy group were 32 patients. Twenty four patients were not diagnosed. There were 11 patients with Aa, 27 patients with Ab, 21 patients with B, 4 patients with C in the vestibulopathy group. There were 5 patients with Aa, 7 patients with Ab, 15 patients with B, 3 patients with C in the non vestibulopathy group. Many of the patients in vestibulopathy group showed Aa or Ab. Most of BPPV patients showed B or C. In the result of A, 75.7% of patients was vestibulopathy group.
Conclusions: The foam posturography analysis system is considered useful and practical method for screening peripheral vestibulopathy in clinical practice.
PP1-78 - Comparing the video Head Impulse to the Suppression Head Impulse as target distance is varied
7. Clinical Testing for Vestibular Function
Leigh McGarvie
1
Hamish MacDougall2, Ann Burgess2, Michael Halmagyi1, Ian Curthoys2
1 Royal Prince Alfred Hospital, Institute of Clinical Neurosciences, Australia
2 University of Sydney, Department of Psychology, Australia
Purpose: Does the different visual stimulus in the video Head Impulse (HIMPs) versus the Suppression Head Impulse (SHIMPs) make a difference at different target distances?
Methods: 10 normal subjects were tested with horizontal HIMPs and SHIMPs at target distances of 120 cm and 50 cm. Gain was calculated by area under the curve for both the full HIMP impulse and the “first half” of both the HIMP and SHIMP impulses to avoid the fastest observed SHIMP saccades which can occur during the “second half”.
Results: In HIMPs there is an increase in VOR gain for the 50cm versus the 120cm distance when gain is calculated over the full impulse of about 7% (eg: rightwards gains mean +/- S.E.M: at 120cm 0.95 +/- .003 : at 50cm 1.02 +/- .004) However, for the HIMPs when gain is calculated during the “first half” of the impulse, the increase is about half of that (eg: rightwards first half gains mean +/- S.E.M: at 120cm 0.77 +/- .004 : at 50cm 0.80 +/- .004) indicating that the extra distance scaling takes place during the later parts of the impulse.
This is not so in the SHIMPs where target distance scaling equivalent to the full HIMP impulse (about 6.5%) takes place during the “first half” (eg: rightwards first half gains mean +/- S.E.M: at 120cm 0.73 +/- .004 : at 50 cm 0. 78 +/- .006).
Conclusions: In addition to slightly reducing the gain of SHIMP versus the HIMP, the different visual stimulus also moves the distance scaling to earlier in the impulse.
PP1-79 - Comparison of video Head Impulse Test with Head Impulse Test and calorics: a retrospective study
7. Clinical Testing for Vestibular Function
Sandrien Mertens
1
Catherine Blaivie1, Erwin Offeciers1, Andrzej Zarowski1, Thomas Somers1, Joost van Dinther1, Robby Vanspauwen1
1 ENT Department, Sint-Augustinus Hospital Antwerp, European Institute for ORL-HNS, Belgium
Purpose: We studied the relationship between Head Impulse Test (HIT) and video HIT (vHIT), and between the caloric test and the vHIT.
Methods: Retrospective clinical study on vHIT, HIT and caloric test patient data. vHIT results were considered unilaterally pathological when: 1) VOR-gain was below 0.79 and 2) when left-right gain-difference was equal or above 0.21 In case of unilateral correction saccades, the vHIT was also considered as unilaterally pathological. In case of a bilateral gain of 0.60 or lower OR in case of bilateral correction saccades, the vHIT was bilaterally pathological.
Results: For the comparison between HIT and vHIT, the time between both tests was limited to 7 days (n=69). In 22 (31.9%) patients, the HIT was pathological. However, only in 36.4% (n=8) of these pathological HITs, the vHIT was also abnormal. In 47 patients (68.1%), the HIT was normal. In 43 (91.5%) of these patients, the vHIT was also normal.
For the comparison between the caloric test and vHIT, the time between both tests was limited to 180 days (n= 164). 93 patients (56.7%) showed pathological caloric results. In this cohort, 22.6% (n=21) and 77.4% (n=72) had abnormal and normal vHIT results respectively. Normal calorics were observed in 71 cases (43.3%), 60 of them (84.5%) also had normal vHIT, and only 15.5% (n=11) showed abnormal vHIT results.
Conclusions: The vHIT is an essential test in a vestibular clinic, giving additional information to the results of the clinical HIT (especially when the HIT is abnormal) and the standard caloric test.
PP1-80 - Comparison of video-head impulse, rotatory chair and bithermal caloric test in vestibular disease
7. Clinical Testing for Vestibular Function
David Barthold1
Holger Rambold
2
1 University of Regensburg, Dept. of Neurology, Germany
2 County Hospitals Altötting-Burghausen, University of Regensburg, Dept. of Neurology, Germany
Purpose: Bithermal caloric irrigation and the video-head impulse test have different sensitivities in identifying various not-acute vestibular disease. The diagnostic benefit of rotatory chair testing in addition to the other two method remains unknown so far.
Methods: We analyzed retrospectively 1600 patients with non-acute vertigo/dizziness which presented to the in- and outpatient clinic of a specialized vertigo/dizziness center in Altoetting, Germany. All patients were routinely examined with the horizontal video-head-impulse test (vHIT), bithermal caloric irrigation (CI) with water and the rotatory intensity damping test (RIDT: initial acceleration 3°/s2, velocity plateau of 90°/s for 120s followed by a sudden stop). To analyze the RIDT test we fitted the data for each direction separately by a non-linear model of vestibular processing including the vestibular, two adaptation and a velocity storage time constant and gain values. Statistical analysis was performed with a multifactorial ANOVA.
Results: Results showed that in identified unilateral vestibular failure (by vHIT and/or CI), RIDT was most sensitive using the velocity ramp compared to the step stimulus and could identify additional vestibular failure in about 5%. Analyzing different diseases showed that on a group level Morbus Menière could be distinguished from vestibular migraine. Rotatory tests altogether were very good in identifying bilateral vestibular failure.
Conclusions: Careful analysis of rotatory chair testing could gain further information in addition to vHIT and CI on a group level, especially using ramp paradigms. Rotatory chair testing should be part of the vestibular test battery.
PP1-81 - Development of real-time video-oculography using high quality infrared video Frenzel.
7. Clinical Testing for Vestibular Function
Makoto Hashimoto
1
Yosuke Okinaka1, Hironori Fujii1, Kazuma Sugahara1, Yoshinobu Hirose1, Takuo Ikeda2, Hiroshi Yamashita1
1 Department of Otolaryngology, Yamaguchi University Graduate School of Medicine, Japan
2 Tsudumigaura medical center for children with disabilities
Purpose: It is essential to use an infrared CCD camera in clinical examination of the vestibular system. Devices are currently available that can quite accurately record human eye movements, based on the principle of video-oculography (VOG). We devised an original VOG (HI-VOG) system using a commercialized infrared CCD camera, a personal computer and public domain software program (ImageJ) for data analysis. In the present study, we revised the VOG and image filing system for real-time 3D analysis of nystagmus, yVOG.
Methods: The video image from a Frenzel with high quality image camera was captured at 60 frames per second at a resolution of 640*480 pixels. For real-time analysis of the horizontal and vertical components, the X-Y center of the pupil was calculated. For real-time analysis of torsional components, the whole iris pattern was overlaid with the same area of the next iris pattern, and the angle at which both iris patterns showed the greatest match was calculated.
Results: Accurate measurements of horizontal, vertical and torsional eye movement were taken while recording the video image in real-time. For quantitative analysis, the slow phase velocity of each occurrence of nystagmus and the average value of the slow phase velocity were analyzed automatically.
Conclusions: Using the revised yVOG system, it was possible to perform real-time quantitative 3D analysis of nystagmus from video images recorded with high quality video Frenzel.
PP1-82 - Differences of VOR gain in the conventional head impulse test and the suppression head impulse test
7. Clinical Testing for Vestibular Function
Go Sato
1
Kazunori Matsuda1, Noriaki Takeda1
1 University of Tokushima School of Medicine, Department of Otolaryngology, JAPAN
Purpose: In this study, we examined some parameters of VOR gain and catch up saccade of the conventional head impulse paradigm (HIMP) and the suppression head impulse paradigm (SHIMP).
Methods: We examined the horizontal semicircular canal function by video head impulse test and caloric test in patients with unilateral vestibular loss (UVL). The examiner performed 20 horizontal head impulses to each side with unpredictable timing and direction for patients.
Results: VOR gain of lesion side of HIMP was positively correlated with that of SHIMP (p<0.01) in patients with UVL. Similarly, between intact side VOR gain of HIMP and SHIMP, we found a positive correlation (p<001). VOR gain of SHIMP was significantly smaller than that of HIMP both with lesion and intact side (p<0.01). Moreover, VOR gain of lesion side of SHIMP was positively correlated with the peak saccade velocity of SHIMP in patients with UVL (p<0.01). There were no correlations between the peak saccade velocity of lesion side both of SHIMP and HIMP in patients with UVL (p>0.05).
Conclusions: We showed that VOR gain of HIMP had more reliable than that of SHIMP because VOR gain of SHIMP might be small by early catch up saccade of SHIMP. The assessment of the peak saccade velocity of SHIMP is easily than that of HIMP because catch up saccade of SHIMP mainly appeared after the head thrust. Thus, the peak saccade velocity of SHIMP was useful for an index of the remaining vestibular function in patients with UVL.
PP1-83 - Effect of gaze direction on vertical VOR gain during the video head impulse test
7. Clinical Testing for Vestibular Function
Jessie Patterson1
Amanda Rodriguez1,
Kamran Barin2, Kristen Janky1
1 Boys Town National Research Hopsital, Audiology, USA
2 The Ohio State University – Dept. of Otolaryngology-Head & Neck Surgery (Emeritus), USA
Purpose: The vestibulo-ocular reflex (VOR) gain for vertical head impulses may be affected by gaze direction due to the presence of torsional eye movements (McGarvie et al. 2015). There are differences in the recommended gaze direction for different devices. The purpose of this study was to investigate the effect of horizontal gaze direction on the vertical VOR across two different video head impulse test (vHIT) devices.
Methods: 24 controls and 3 subjects with bilateral vestibular loss have participated. One experienced clinician administered vHIT in the plane of the left anterior and right posterior (LARP) canals using ICS Impulse (Otometrics) and EyeSeeCam (Interacoustics). LARP impulses were performed at three gaze angles (+45, 0, -45).
Results: For controls, VOR gains were generally higher for EyeSeeCam. For both devices, when the gaze was aligned with the plane of the stimulated canals (+45), VOR gains were higher and decreased as gaze moved away from the plane of the canal (0, -45). However, the gains became abnormal only when the gaze direction was aligned with the opposite canal pairs (-45). Repeatable reset saccades were not observed. In the three bilateral vestibular loss subjects, gains were low with repeatable reset saccades but no differences were noted for different gaze directions. Data collection is ongoing for vestibular patients.
Conclusions: Gaze direction affects vertical VOR gains; however, gains are within normal limits for both devices when performed according to each manufacturer’s protocol.
PP1-84 - Effect of intratympanic gentamicin injection on lateral and vertical canals using HIMPs and SHIMPs
7. Clinical Testing for Vestibular Function
Catherine de Waele
1
Qiwen Shen2, Christophe Magnani2, Georges Lamas3, Ian Curthoys4
1 Cognition and Action Group, CNRS UMR8257, University of Paris Descartes, Paris, France; ENT Department, Pitie Salpetriere Hospital, Paris, France
2 Cognition and Action Group, CNRS UMR8257, University of Paris Descartes, Paris, France
3 ENT Department, Pitie Salpetriere Hospital, Paris, France
4 Vestibular Research Laboratory, University of Sydney, NSW, Australia
Purpose: This study is to determine whether intratympanic gentamicin injection (ITG) similarly affects all three semicircular canals in patients suffering from Menière’s disease, and whether the decrease of vestibulo-ocular reflex (VOR) gain in lateral and vertical planes correlated with vertigo control six months after the last injection.
Methods: 34 patients suffering from Menière’s disease and treated by ITG were tested before and six months after the injection. The gain of VOR in all three canals was quantified by HIMPs and SHIMPs. Whether patients had complaint on rotatory vertigo was systematically asked before each test. Horizontal VOR gain inferior to 0.8 and vertical VOR gain lower than 0.7 were considered as lesioned.
Results: Lateral canals were always lesioned with a gain ranging from 0.38 to 0.74. All these patients were areflexic to Caloric test and exhibited vibratory-induced ocular nystagmus with quick phase oriented towards the intact side. In contrast, in 47% and 35% patients, anterior and posterior canals were not affected. Nevertheless, patients with lesion on horizontal but not vertical canals had no complaint on rotatory vertigo after the last injection.
Conclusions: ITG injection caused a significant decrease of HVOR gain in all patients. However, the gain of posterior and anterior canals could be within normal range after the last injection. Moreover, a residual function of the lateral and vertical canals is always observed, in contrast to vestibular neurectomy. Despite different sensitivity to gentamicin in three canals, the loss of HVOR itself appears to ensure the control of vertigo recurrence.
PP1-85 - Eliciting cVEMPs and oVEMPs from newborns through the elderly-a review
7. Clinical Testing for Vestibular Function
Yi-Ho Young
1
Shuo-Yen Hsu1
1 Department of Otolaryngology, National Taiwan University Hospital, Taiwan
Purpose: This study reviewed our experience in eliciting cervical and ocular vestibular-evoked myogenic potentials (cVEMPs and oVEMPs) from newborns via children, adolescents, adults to the elderly.
Methods: Loud sound stimuli were utilized to elicit oVEMPs and cVEMP in children aged below 3 years old. For small children and the elderly who cannot maintain neck contraction, cVEMP test can be performed by head rotation method instead of head elevation method. For small children who cannot maintain upward gaze, oVEMP test was conducted by eyes closed method. For young adults, tapping at the Fpz site is preferred for eliciting bilateral oVEMPs, if fails, tapping at the Fz site alternatively. If both Fpz and Fz taps fail to induce oVEMPs, tapping at the mastoid is performed to assess the residual otolithic function.
Results: The cVEMPs can be elicited in newborns at day 5, whereas the oVEMPs are absent in neonatal period. When children grow to 2 years old, the oVEMPs can be induced with eyes closed condition, while the oVEMPs with eyes up condition can be elicited in children aged > 3 years old, with the characteristic parameters similar to adult levels. In contrast with cVEMPs, it is until the neck length > 15.3 cm, one need not account for neck length in evaluating cVEMP latency. For those elderly aged > 60 years, absent oVEMP and cVEMP may arise from either underlying pathology or aging effect.
Conclusions: Defining appropriate test stimuli/paradigms in subjects of various ages may improve the reliability of the oVEMP and cVEMP results, which is in evolution.
PP1-86 - Eye tracking during caloric nystagmus: a sensitive test to identify central vestibular disorder
7. Clinical Testing for Vestibular Function
Hiroaki Fushiki
1
Mayumi Endo1, Reiko Tsunoda1, Yukio Watanabe2
1 Mejiro University Ear Institute Clinic, Otolaryngology, Japan
2 Osawano Long-Term Care Health Facility, Kagayaki, Japan
Purpose: In 1975, Sakata et al. demonstrated that eye-tracking patterns during caloric nystagmus (CN) were useful for differentiating between peripheral and central vestibular disorders (CVD). We report that the degree of suppression of CN by eye-tracking could be a sensitive indicator for detection of central vestibular disorders.
Methods: For induction of CN, the subjects were placed in a supine position with the head anteflexed at 30 degrees and their ear was stimulated with cold air (10°C) for 60 s. After CN was established, subjects were instructed to follow a target oscillating with 30° amplitude, at a frequency of 0.3 Hz. A total of 32 waveforms during 3 eye-tracking periods were quantitatively examined with spectral analysis by discrete Fourier transformation; these were obtained from 14 ears of 7 healthy subjects and 18 ears of 9 patients with central vestibular disorder. The CN induced by eye-tracking was compared with that induced by visual-fixation.
Results: Unlike in healthy subjects, eye-tracking during CN was not maintained smoothly in most patients with central vestibular disorder, including patients who showed normal visual-fixation. The suppression-rates of CN by eye-tracking were 72.0% ± 8.6 for healthy subjects and 36.3% ± 19.6 for patients when the eye-tracking was directed to the slow phase of CN, and 65.1% ± 14.9 and −2.1% ± 42.0 respectively, when the eye-tracking was directed to the fast phase.
Conclusions: Eye-tracking during CN is a sensitive diagnostic method for detection of central vestibular disorder.
PP1-87 - Functional Measure of Gaze Shifting in Healthy and Unilateral Vestibular Hypofunction Individuals
7. Clinical Testing for Vestibular Function
Chung-Lan Kao
1
Po-Yin Chen2, Lieber Po-Hung Li3, Michael C Schubert4
1 Department of Physical Medicine & Rehabilitation, National Yang-Ming University & Taipei Veterans General Hospital, Taiwan
2 Institute of Physical Therapy and Assistive Technology, National Yang-Ming University, Taiwan
3 Otolarygology and Medical Center for Hearing Loss, Cheng Hsin General Hospital, Taiwan
4 Department of Otolaryngology Head and Neck Surgery, Department of Physical Medicine and Rehabilitation, Johns Hopkins University, USA
Purpose: A gaze shift involves an initial eye rotation to the target of interest, followed by a head rotation towards the same target. We incorporated dynamic visual acuity test to develop a functional measure of gaze shift called gaze shift DVA (gsDVA) and compared the differences among the young (< 65 y/o) vs (65 y/o) populations and patients with unilateral vestibular hypofunction.
Methods: At the beginning of the test, the center monitor flashed an arrow randomly pointed to the left or right. The subject followed the direction given and turned her/his head to the left/right side monitor until the central axis of the face was aligned with the monitor. Once the subject’s head rotated to a 60-degree range, an optotype would flash on the side monitor for the subject to identify its orientation. The Optotype would disappear after an examiner entered the response. gsDVA, reaction time (RT) and head velocity were measured both in stance and walking at a self-selected speed.
Results: We recruited a total of n=105 subjects (71 healthy; 21 left and 13 right vestibular hypofunction). gsDVA was worse healthy subjects aged 60-80 years, followed by gsDVA in 20-40y/o, and best in 40-60 y/o. Patients with UVH displayed worse gsDVA scores during ipsilesional head rotation
Conclusions: Significantly reduced gsDVA was found in the old. This phenomenon was also noted in vestibular hypofunction patients on ipsilesional gsDVA. We believe this measure will be a useful metric in evaluating dynamic visual acuity in different age groups and patients with vestibular hypofucntion.
PP1-88 - Head Movement During Functional Gait Assessment Predicts Clinical Measures in Vestibular Patients
7. Clinical Testing for Vestibular Function
Gavin Mischler1
Omid Zobeiri2, Susan King3, Richard Lewis3, Kathleen Cullen1
1 Johns Hopkins University, Baltimore, USA
2 Mcgill University, Montreal, Canada
3 Harvard University, Boston, USA
Purpose: A wide range of functions, from basic reflexes to high-level behaviors, depend on the vestibular system. It has been shown that following unilateral vestibular loss, patients experience dizziness, headache, and impaired balance, postural, and gaze control. Here, we assessed whether functional Gait Assessment Can Predict Clinical Measures in Vestibular Schwannoma Patients
Methods: Head movements were recorded during Functional Gait Assessment (FGA) using a six dimensional motion sensor in (1) healthy volunteers and (2) patients before and six weeks after surgery. We computed measures of gait speed, asymmetry, and variability during FGA and then compared these with the clinical measures; dizziness handicap inventory (DHI), activities-specific balance confidence (ABC), Beck anxiety inventory (BA), FGA score, postural sway, and vestibulo–ocular reflex gain.
Results: Our results showed negligible correlations between gait parameters and clinical measures in the healthy volunteers. In contrast, we found significant correlations with multiple clinical measures in patients. First, before surgery, patients with higher head movement variability during walking also had larger postural sway. Correlations between gait parameters and clinical measures were even more common six weeks after surgery. Notably, gait variability correlated with multiple the clinical measures. Moreover, patients with lower anxiety and dizziness and higher confidence and FGA scores showed higher variability, and patients who walked faster had more dizziness and less FGA scores.
Conclusions: Taken together, our results suggest that computed measures of gait speed, asymmetry, and variability from the FGA can be a predictor of the clinical measures and can be used for monitoring patients with unilateral vestibular loss.
PP1-89 - High-frequency VOR in certain Hydropic Ear Disease
7. Clinical Testing for Vestibular Function
Claudia Jerin1
Rebecca Maxwell1,
Robert Gürkov
2
1 University of Munich, Otorhinolaryngology & German Vertigo Centre, Germany
2 University of Munich, Otorhinolaryngology, Germany
Purpose: Little is known about the VOR physiology in Hydropic Ear Disease (Menière’s Disease), and previous studies have yielded variable results, partly due to a mainly symptom-based diagnostic verification. Here, we present the first detailed study of the VOR in a well-defined patient population with certain Hydropic Ear Disease with maximal diagnostic accuracy.
Methods: 54 patients with certain Hydropic Ear Disease, i.e. clinically definite Menière’s Disease according to the AAO-HNS criteria and evidence of endolymphatic hydrops on magnetic resonance imaging were included. Patients were examined with video head impulse test (vHIT), caloric videonystagmography, VEMP and audiometry.
Results: Clearly pathological vHITs with a gain below 0.7 were relatively rare (13%) in patients with certain Hydropic Ear Disease. However, the majority of patients (61%) revealed refixation saccades with a saccade frequency of > 50%. The VOR gain was highly significantly correlated with saccade frequency and velocity. There was no correlation between vHIT gain/saccade frequency/saccade velocity and caloric canal paresis/VEMP/audiometry. Furthermore, refixation saccades were not correlated with disease duration, in contrast to the situation in acute peripheral vestibulopathy.
Conclusions: When examining the vHIT in patients with suspected Hydropic Ear Disease, it is important to not only consider the VOR gain, but also examine refixation saccades. The occurrence of refixation saccades may be an indicator for an impaired VOR even in the presence of a “normal” VOR gain value. Furthermore, the process of vestibular compensation seems to be impaired in Hydropic Ear Disease, probably due to the fluctuating nature of the disease.
PP1-90 - Horizontal ocular deviation on brain MRI in acute vertigo patients
7. Clinical Testing for Vestibular Function
Min Tae Kim1
Yeon-Jun Yang1, Ji Eun Choi1, Min Young Lee1,
Jae Yun Jung
1
1 Dankook university, ORL-HNS, South Korea
Purpose: Magnetic resonance imaging (MRI) has been increasingly used for screening central acute vertigo in the ER. Recently horizontal ocular deviation (OD, measured from T2 MRI) is shown to well correlate with vestibular function tests which reflect the vestibular static and dynamic imbalance and can be used ss an indicator of unilateral vestibular weakness. The aim of this study is to compare the horizontal OD among different disease and to evaluate the correlation of OD direction and lesion side in each disease respectively.
Methods: This study was retrospective review including 188 patients who visited ER due to acute vertigo. The final clinical diagnosis are as followed: BPPV, definite Meniere’s disease (dMD), probable and possible MD (pMD), migraine associated vertigo (MAV), vestibular neuritis (VN), and others. PICA infarction patients was also included. The control group included 30 healthy individuals without previous vertigo history or ophthalmopathy. OD was quantified by using the axial planes of the eyeball lenses in T2 brain MRI.
Results: Acute vertigo patients showed variable OD value depending on diagnosis. The average value of absolute OD in dMD (19.5° ± 12.2°), pMD (15.8° ± 11.2°), VN (22.8° ± 10.6°) was significantly higher than that of control (5.9° ± 3.0°) (p<0.01). BPPV did not show abnormal OD compared to control. VN showed statistically higher lesion side OD. MD, PICA showed contralesionside OD (43%) compared to control.
Conclusions: Horizontal OD reflecting the vestibular imbalance was variable depending on pathology and significantly higher in MD, pMD, VN and PICA patients than in control group.
PP1-91 - How many sweeps are needed for Clincal OVEMP testing
7. Clinical Testing for Vestibular Function
Anouk Kuijpers1
Art Malllinson1, Neil Longridge2
1 University of British Columbia, Department of Surgery; Vancouver General Hospital, Vancouver, CANADA
2 University of British Columbia, Department of Surgery; Vancouver, CANADA
Purpose: OVEMPs in our hands provide us with reproducible and consistent results but it has been shown that OVEMP amplitude decreases with increased stimulus duration. The exact number of stimuli for OVEMP recording is not consistent through the published papers describing this test. We wished to determine how many stimuli are needed to produce a satisfactory OVEMP response and the consequences of more prolonged stimulation to the OVEMP response.
Methods: We retrospectively analyzed our previous 50 OVEMP patient recordings and found that the average number of sweeps carried out was 26. We carried out 3 different OVEMP recordings; using our standard protocol of 1 a “standard” OVEMP recording without looking at the number of sweeps and recording until the OVEMP wave becomes obvious. 2 OVEMP recording with our average of 26 sweeps. 3 OVEMP recording with twice as many sweeps.
Results: OVEMP latencies did not change when using different numbers of sweeps, but amplitudes showed a significant decrease with an increasing number of sweeps.
Conclusions: OVEMPs can be completed in a satisfactory manner with a much lower number of stimuli than are usually carried out. Reducing stimulus number reduces the time that the test takes, minimizes the cochlear insult while not reducing the valuable information obtained, and maximizes the amplitude of the stimulus, possibly increasing accuracy of measuring interaural amplitudes, helping to measure asymmetry.
PP1-92 - How well does clinical history correlate with results of vestibular assessment?
7. Clinical Testing for Vestibular Function
Art Mallinson
1
Neil Longridge2, Lillian Wong3
1 University of British Columbia, Department of Surgery; Vancouver General Hospital, Vancouver, CANADA
2 University of British Columbia, Department of Surgery, Vancouver, CANADA
3 University of British Columbia, Department of Surgery; Vancouver, CANADA
Purpose: It is well documented that patient histories do not correlate with abnormal test results. It is also well established that normal test results do not rule out pathology, and we wished to test this hypothesis in a controlled manner. This study tested the intuition of two Neuro-otologists to predict test results based only on history and clinical exam. In addition, the assessor of all the patients also used his intuition to try and determine if the Neuro-otologists would be successful in their predictions.
Methods: All patients underwent a full battery of tests (VEMPs. Calorics, posturography, HIT). The neuro-otologists predicted the abnormalities after history taking and patient examination but before being supplied with any results.
Results: Theere was very poor accuracy of prediction and discussion of the usefulness of clinical assessments related to measured abnormalities. The assessor of the patients (who had taken a detailed history and carried out all assessments) was also poor at predicting what conclusions would be arrived at by the clinicians.
Conclusions: The paramount factor in assessing a dizzy patient is in the history. Normal test results do not override a history, and abnormal results assist in confirming the clinical impression.
PP1-93 - Isolated posterior canal hypofunction on video-HIT: association with additional inner ear deficits
7. Clinical Testing for Vestibular Function
Andrea Castellucci 1,2
1
Cristina Brandolini 12, Gianluca Piras 1,33, Valeria Del Vecchio 12, Giovanni Carlo Modugno 12, Angelo Ghidini 24, Antonio Pirodda 12
1 1. ENT & Audiology Unit, DIMES, Sant’Orsola – Malpighi University Hospital, Bologna, Italy. 2. ENT Unit, Department of Surgery, AUSL – IRCCS, Reggio Emilia, Italy
2 1. ENT & Audiology Unit, DIMES, Sant’Orsola – Malpighi University Hospital, Bologna, Italy.
3 1. ENT & Audiology Unit, DIMES, Sant’Orsola – Malpighi University Hospital, Bologna, Italy. 3. Department of Otology and Skull Base Surgery, Gruppo Otologico, Piacenza, Italy
4 2. ENT Unit, Department of Surgery, AUSL – IRCCS, Reggio Emilia, Italy.
Purpose: Since video head impulse testing (vHIT) has been introduced, a functional assessment of each semicircular canal (SC) has been easily provided in clinical setting. Isolated posterior SC (PSC) hypofunction, though occasionally described, has not been extensively characterized yet. Here we aimed to assess all different patterns of concomitant abnormalities on audiometry, caloric test (CT) and cervical/ocular VEMPs by air/bone conduction in patients with isolated PSC hypofunction and to correlate with underlying diagnoses.
Methods: We retrospectively reviewed the clinical and instrumental records of 49 patients with isolated PSC hypofunction (25 right, 23 left, bilateral in 1 case). We determined vHIT gains and correlated them with other instrumental data.
Results: Recent or previous acute vestibular deficit (AVD) was diagnosed in 12 patients (24.5%, 8 with cochlear involvement), Meniere’s disease (MD) in 11 (22.4%) and cerebellopontine angle (CPA) lesion in 9 (18.4%). Additional abnormalities on BCT and/or VEMPs due to horizontal SC and/or maculae involvement was seen in 85% of patients. Cochlear involvement was diagnosed in 69% with pure tone average significantly higher in patients with AVD with hearing loss (p < 0.05). Overall involvement of labyrinthine receptors or afferents was highest in patients with AVD with hearing loss (p < 0.01) and CPA lesion (p < 0.05).
Conclusions: Isolated loss of PSC function on vHIT is mostly accompanied by additional labyrinthine deficits. It should always be tested in patients with vestibulo-cochlear symptoms. Assessment of all inner ear receptors and afferents is mandatory in order to identify the site of the lesion, thus hypothesizing underlying pathophysiological mechanisms.
PP1-94 - New protocol to optimize ocular-VEMP stimulation and recording with High-Force Level Bone Conductors
7. Clinical Testing for Vestibular Function
Andy J Beynon
1
Jasper B Van der Heijdt1, Machteld J Boonstra1
1 Radboud University Medical Centre Nijmegen, The Netherlands
Purpose: Ocular vestibular evoked myogenic potentials (oVEMPs) provide information about utricular function and neural pathway between utriculus and inferior oblique muscle. Although oVEMPs are more easily obtained by using high-force level bone conductors (HFBC) instead of clinical B71 or B81 bone conductors, clinical protocols for HFBC recordings are lacking.
The aim of this study is to investigate the use of different stimuli, different scalp locations and different electrode recording configurations for clinical implementation of oVEMPs using HFBC
Methods: Subjects (n=20) without neuro-otological medical history underwent oVEMP testing using different parameter settings: 1) oVEMP responses of bone-conducted (BC) stimuli are obtained at different scalp locations (Cz, Fz, M1/2) to uni- and bilateral responses 2) stimuli consist of 250 to 1000 Hz tone bursts, generated by a high-force level B&K 4810 ‘Mini-Shaker’. Response amplitude (uV), latency (ms), response reproducibility (%), inter-ocular ratio (%) and vibratory stimulation threshold (dBFL) were determined for different tapping scalp positions. Left- and right oVEMP responses (inter-ocular ratio: IOR) were compared.
Results: Significant differences in response amplitude, latency, response reproducibility and IOR were found depending on tapping scalp position. Left- and right differences were most prominent during mastoid stimulation. Tone burst stimuli with rise-plateau-fall times of 1-1-1 ms of 500 Hz reveal best oVEMPs when presented at Fz with single reference recordings and bilateral belly-tendon locations of the inferior oblique muscles.
Conclusions: An new improved standard clinical protocol is proposed for clinical assessment of oVEMPs with HFBC stimulators
PP1-95 - Non compensation in the vestibular patient
7. Clinical Testing for Vestibular Function
Lillian Wong
1
Art Mallinson2, Neil Longridge3
1 University of British Columbia, Department of Surgery, Vancouver, CANADA
2 University of British Columbia, Department of Surgery; Vancouver General Hospital, Vancouver, CANADA
3 University of British Columbia, Department of Surgery; Vancouver, CANADA
Purpose: VEMP assessment is a powerful diagnostic assessment. Documented abnormalities can persist for long periods of time, in which case compensation is required. We oftenn see patients who have had persistent problems for years. These abnormalities can persist, but do not give an indication of clinical recovery. Computerized dynamic posturography however in our hands, is a more effective measure of a patient’s clinical recovery.
We have wondered why certain patients do not compensate. History taking is of utmost importance in these patients as some of them have a history of more than one discrete event (either traumatic or nontraumatic). This suggests sequential contralateral or ipsilateral pathology, which presents an added challenge to compensate for.
Methods: We studied patients who had suffered only one discrete event and compared them to patients who had suffered multiple vestibular events. We looked at posturography performance in both groups of patients.
We have always wondered why some patients complain predominately of nausea and others predominately of imbalance. The presence of autonomic symptoms may inhibit compensation due to reduced physical activity. We also documented autonomic symptoms in our “single event” and the “multiple event” patients.
Results: Although VEMP assessment was similar in our two groups of patients, we found that patients with a histroy of multiple events and with a predominance of autonomic symptoms compensated less effectively as shown on posturography.
Conclusions: Recovery after a significant single vestibular event is better than with multiple events, and patients with persistent autonomic symptoms do not do as well.
PP1-96 - Normal values of video-head impulse test for healthy people in different age
7. Clinical Testing for Vestibular Function
Wei Fu
1
Feng He2, Junliang Han2
1 Fourth Military Medical University, Xijing Hospital, Department of Geriatrics, China
2 Fourth Military Medical University,Xijing Hospital, Department of Neurology, China
Purpose: To explore the normal values of video-head impulse test (vHIT) and age-related changes in healthy volunteers.
Methods: One hundred and eleven healthy volunteers were distributed to seven age groups, all subjects accepted video-head impulse tests. The vestibulo-ocular reflex (VOR) gain and gain asymmetry ratio were analyzed and compared among groups.
Results: For all the healthy subjects, the mean horizontal VOR gain was 1.04±0.09(range: 0.70-1.26), the mean anterior VOR gain and the posterior VOR gain were 0.89±0.13(range:0.61-1.25) and 0.88±0.12(range:0.62-1.24). There were no significant differences among different age groups in horizontal VOR gain and in vertical VOR gain(P0.05).The mean left and right horizontal gain asymmetry ratio was 6.83±4.01%, the mean left-anterior and right-posteriorLARPgain asymmetry ratio and the mean right-anterior and left-posteriorRALPgain asymmetry ratio were 6.03±5.31% and 7.36±5.03%. There were no significant differences among different age groups in gain asymmetry ratio (P0.05).
Conclusions: There were no obvious age-related changes in VOR gain and gain asymmetry ratio in healthy people.
PP1-97 - Outcome prediction of sudden sensorineural hearing loss using neurotological tests
7. Clinical Testing for Vestibular Function
PO-WEN CHENG
1
CHITE WANG1, YI-HO YOUNG2
1 Far Eastern Memorial Hospital, Department of Otolaryngology, Taiwan.
2 National Taiwan University Hospital, Department of Otolaryngology, Taiwan
Purpose: This study investigated whether audiovestibular function tests, namely auditory brain stem response (ABR) and vestibular-evoked myogenic potential (VEMP) tests were correlated to hearing outcomes in sudden sensorineural hearing loss (SSHL).
Methods: Patients with sudden SSHL were enrolled in this study. Pretreatment hearing levels, results of audiovestibular function tests, and final hearing outcomes were recorded from retrospective chart reviews. Other factors, including age, gender, delay of treatment, vertigo, diabetes mellitus, and hypertension, were collected as well. Comparative analysis between multiple variables and hearing outcomes was conducted using the cumulative logits model in overall subjects.
Results: Multivariate analysis showed that pretreatment hearing levels, presence of vertigo, and results of ABR and VEMP testing were significant outcome predictors in the overall subjects. Stratification analysis demonstrated that both the presence of ABR and VEMP waveforms were significantly correlated with better hearing outcomes in the group of severe SSHL, whereas the presence of vertigo was the only significant negative prognostic factor in the group of profound SSHL
Conclusions: ABR and VEMP tests should be included in the battery of neurootological examinations in patients with severe SSHL because the presence of both waveforms might indicate favorable hearing outcomes.
PP1-98 - Postural control, vestibular restoration and disability perception in vestibular neuritis
7. Clinical Testing for Vestibular Function
Jonathan Esteban Sanchez
1
Ricardo Sanz Fernandez1, Eduardo Martin Sanz1
1 University Hospital of Getafe - Otoneurology Unit - Getafe, Madrid (Spain)
Purpose: To evaluate vestibular restoration and the evolution of the compensatory saccades in vestibular neuritis and its correlation with computerized dynamic posturography (CDP) values and disability questionnaires.
Methods: Longitudinal and prospective study of 27 consecutive patients diagnosed of vestibular neuritis. After the initial diagnosis, every patient was followed up in a three-month basis for at least 12 months. vHIT, Caloric and Vestibular Evoked Miogenical Potentials were performed in the moment of the diagnosis. Subsequently vHIT, was performed 1 week, 1 month, 3 months, 6 months and 12 months after the initial diagnosis. A Computerized Dynamic Posturography and disability questionnaires were completed every three months.
Results: The different vHIT tests showed a progressive VOR restoration along the time.A pattern of decrease in the velocity and latency values of the saccades, and a progressive grouping was identified. A significant correlation between the vHIT gain values and the sensory organization test as with the disability questionnaires, were observed. There is a significant correlation between evolution disabillity questionnaires punctuation and vHIT gain and also with postural control described in CDP.
Conclusions: The VOR restoration, the reduction of latency and velocity and the organization of compensatory saccades play a role in vestibular compensation. These findings have a significant influence in postural control and the perceived disability of the patients
PP1-99 - Posturographic pattern of patients with peripheral vestibular dysfunction at vertigo interval period
7. Clinical Testing for Vestibular Function
Kotaro Shimizu
1
Takao Imai1, Takashi Sato1, Yasuhiro Osaki1, Yumi Ohta1, Hidenori Inohara1
1 Department of Otorhinolaryngology-Head and Neck Surgery, Osaka University, Osaka, Japan
Purpose: Posturography (PG) is used to study equilibrium-functions, but the accuracy to detect the focus of peripheral vestibular disease (PVD) is unclear. This study aimed to examine the difference of PG pattern in PVD patients.
Methods: In this study, 425 patients were examined PG parameters at first meeting. 220 patients with Meniere’s disease, 101 patients with posterior canal type benign paroxysmal positional vertigo (P-BPPV), 53 patients with horizontal canal type BPPV (H-BPPV), 20 patients with sudden hearing loss with vertigo and 31 patients with vestibular neuritis were included. In 126 patients, caloric test was performed. We studied relationship of damaged side and mean value of center of left to right movement (MX). In patients who were performed caloric test, we evaluated the relationship of canal paresis side and MX.
Results: There were significant differences at total length movement (LNG) with eyes open and closed between patients with Meniere’s disease and patients with BPPV. In addition, there was a significant difference in age between patients with Meniere’s disease and patinents with BPPV. Multiple analysis was performed, age was correlate with LNG, and the difference between patients with Meniere’s disease and patients with BPPV was negative. There were no correlations with PG parameters and damaged side, and canal paresis side. In any PG parameters, there were no significant differences between patients with P-BPPV and patients with H-BPPV.
Conclusions: There was significant difference between patients with Meniere’s disease and patients with BPPV, but it depended only on the age distribution.
PP1-100 - Preliminary results of video Head Impulse Testing (vHIT) in children with dizziness or vertigo
7. Clinical Testing for Vestibular Function
Chen Jianyong
1
Jun Yang1, Wei Wang1, Ling Mei1, Qing Zhang1, Xiaobao Ma1, Xiangping Chen1
1 Deparment of Otolaryngology Head & Neck Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, China
Purpose: This study was to describe our preliminary experience with vHIT in children with dizziness or vertigo, and determine its efficacy for detecting dysfunction of the semicircular canals in this population.
Methods: 48 children (21 males and 27 females, age range 4-12 years) with different types of vertigo or dizziness were performed. All these children without hearing loss or absence of skull abnormality as assessed by CT scan or MRI. The caloric test was performed with air at two different temperatures in which both ears were irrigated alternately. Then, the video head-impulse test was carried out. Main outcome measures were the gain of vestibulo-ocular reflex, gain asymmetry, and refixation saccades in the vHIT.
Results: In all subjects, 30 children complete the bithermal caloric tests, 19 patients were normal and the other 11 patients were abnormal. By vHIT, in 30 patients (62.5%) is, while abnormal findings were found in 18 patients (37.5%). Single canal affection was seen in 8 patients whereas 10 patients had combined canal affection. The right side was affected in 15 and left side in 17 patients. The most common pattern was affection of right posterior canals and left posterior canals. The average gain in different canals was 1.06±0.24, 1.08±0.22, 1.00±0.32, 0.90±0.32,1.22±0.37, 1.67±0.35 in Horizontal left, Horizontal right, Left anterior, Right posterior, Right anterior, Left posterior, respectively.
Conclusions: vHIT is a simple tool to evaluate each of the 6 semicircular canals in children, which can offers some potential clinical information for assessing the vestibular dysfunction in children with dizziness or vertigo.
PP1-101 - Quantitative analysis of smooth pursuit eye movement by video-oculography (VOG)
7. Clinical Testing for Vestibular Function
Kazuma Sugahara
1
Hironori Fujii1, Makoto Hashimoto1, Yoshinobu Hirose1, Takuo Ikeda2, Hiroshi Yamashita1
1 Department of Otolaryngology, Yamaguchi University Graduate School of Medicine, Japan
2 Tsudumigaura medical center for children with disabilities, Japan
Purpose: Abnormalities of smooth pursuit eye movement (SPEM) are a clinical finding in central equilibrium disorders. In recent years, the evaluation of SPEM using video-oculography (VOG) has been conducted clinically. However, evaluation criteria for determining a saccadic pattern have not been clearly defined. In this study, we report SPEM using VOG performed with commercially available equipment. The results were then quantitatively evaluated.
Methods: Twelve patients treated at the Department of Otolaryngology at our hospital underwent SPEM testing using simultaneous electronystamography (ENG) and VOG. Eye movements were binarized using ImageJ software and these data were used for statistical analysis. Evaluation criteria included the number of saccadic eye movements, average eye movement velocity, average difference between target and eye movement velocities, and phase lag between target and eye movements.
Results: We examined a healthy pattern group (n = 6) and saccadic pattern group (n = 6). A significant difference between the healthy and saccadic pattern groups in the number of saccadic eye movements, average eye movement velocity, and average difference between target and eye movement velocities were identified.
Conclusions: Quantitative evaluation of SPEM using VOG was possible and useful evaluation criteria were identified. SPEM testing can non-invasively evaluate brain stem and cerebellar function. Screening may be possible using this simple method.
PP1-102 - Relationship of Vestibulo Ocular Reflex and Gait in Patients with Vestibular Schwannoma
7. Clinical Testing for Vestibular Function
Ondˇej Čakrt
1
Zdeňek Čada2, Kryštof Slabý1, Jaroslav Jeˇábek3
1 2nd Faculty of Medicine, Charles University in Prague and Motol University Hospital, Department of Rehabilitation and Sports Medicine, Czech Republic
2 1st Faculty of Medicine, Charles University in Prague and Motol University Hospital, Department of Otorhinolaryngology, Head and Neck Surgery, Czech Republic
3 2nd Faculty of Medicine, Charles University in Prague and Motol University Hospital, Department of Neurology, Czech Republic
Purpose: Growth of vestibular schwannomas (VS) causes progressive vestibular symptoms and postural instability. Since the tumor grows slowly, compensation of disturbing vestibular input may decrease subjective symptoms of dizziness. The goal of this study was to determine if testing of static and dynamic vestibulo ocular reflex correlates with clinical gait tests in patients with VS.
Methods: A prospective review of 18 patients newly diagnosed with VS. The results of vestibulo ocular tests including dynamic visual acuity during passive head motion and deviation of subjective visual vertical. These outcome measures were compared to results of Timed Up and Go Test, Four Step Square Test, Functional Gait Assessment and Tinetti Performance Oriented Mobility Assessment. Nonparametric Spearman’s correlation was used for statistical analysis.
Results: There was significant correlation between deviation of subjective visual vertical and dynamic visual acuity. We did not observe significant correlation between deviation of subjective visual vertical and gait tests but significant correlation between dynamic visual acuity test and Timed Up and Go Test, Four Step Squere and Tinetti Performance Oriented Mobility Assessment was found.
Conclusions: We found possible effects of dynamic vestibulo ocular reflex dysfunction on walking impairment. Our findings confirmed that dynamic visual acuity test correlate significantly with gait tests in patients diagnosed with VS.
PP1-103 - Reliability of the Suppression Head Impulse Test and Role of Test Predictability
7. Clinical Testing for Vestibular Function
Khalid Alahmari
1
Sarah Alshehri2
1 King Khalid University
2 King Khalid Univeristy
Purpose: Suppression Head Impulse Paradigm (SHIMP) was recently discovered as a version of vHIT protocol that provides additional information about the vestibule-Ocular Reflex (VOR) in vestibular dysfunction. Objectives: To examine the test-retest reliability of (SHIMP) and to test the influence of predictability on the latency of SHIMP saccadic responses for both healthy participants and participants with vestibular function deficiency.
Methods: The study included 3 patients with unilateral vestibular hypofunction and 5 healthy subjects. Participants were tested twice by two examiners. SHIMP eye movements responses were recorded with the Video Head Impulse Test. SHIMPS were performed by turning the head 10 times at high velocities to the left and to the right side, respectively. Every examiner performed the test in two different algorithms: predictable SHIMP and unpredictable SHIMP depending on the target predictability. Saccades latency and velocity and VOR gain were recorded for every subject.
Results: The intraclass correlation coefficient (ICC) of the test-retest of SHIMP by two examiners was at least (0.746) in both latency and velocity of the SHIMP saccadic responses in both groups (p<0.01). There was no significant influence of the predictability of head movement between the two groups.
Conclusions: The reliability of SHIMP test was demonstrated in our study, but the lack of the influence of the predictability may be related to the small number subjects included in our preliminary study.
PP1-104 - Simultaneous recording of cervical and ocular vestibular-evoked myogenic potentials
7. Clinical Testing for Vestibular Function
Hyun-June SHIN
1
Rainer Boegle2, Matthias Ertl2, Peter zu Eulenburg2, Ji-Soo Kim3, Marianne Dieterich2, Sun-Young Oh4
1 Department of Neurology, Chonbuk National University Hospital, Jeonju, Republic of Korea
2 Department of Neurology, University Hospital, Ludwig-Maximilians-University, Munich, Germany
3 Department of Neurology, Seoul National University School of Medicine, Seoul, Republic of Korea
4 Department of Neurology, Chonbuk National University School of Medicine, Jeonju, Republic of Korea; Department of Neurology, University Hospital, Ludwig-Maximilians-University, Munich, Germany
Purpose: To improve the clinical application of vestibular-evoked myogenic potentials (VEMPs) in real-world practices, we evaluated whether simultaneous recording of ocular and cervical VEMPs could be achieved while preserving diagnostic accuracy compared to conventional recording methods.
Methods: Simultaneous recording of ocular and cervical VEMPs on each side during monaural stimulation, bilateral simultaneous recording of each VEMP with binaural stimulation, and conventional sequential recording of both VEMPs on each side using air-conducted sound (500 Hz, 5ms tone-burst) were investigated in healthy controls (n=40) and in patients with acute vestibular neuritis (n=20).
Results: Either simultaneous recording during monaural and binaural stimulation effectively reduced the testing time less than 60% of that for conventional sequential recordings in both healthy controls and the patients group. The simultaneous recording with monaural stimulation led to plausible evoked potentials in terms of latencies, thresholds, and amplitudes as in the conventional recording methods, except for larger ocular VEMP amplitudes (156%) in both groups. In contrast, simultaneous recording of each VEMP during binaural stimulation showed amplitudes attenuation (31%) and increased thresholds for cervical VEMPs in both groups.
Conclusions: Simultaneous recording of cervical and ocular VEMPs using monaural stimulation elicited eletrodiagnostic indices without a loss of diagnostic validity whilst reducing the time to record both VEMPs on each side.
PP1-105 - Splenius capitis: Target for the cVEMP in older and neurodegenerative patients
7. Clinical Testing for Vestibular Function
Martin Westling
1
Fatema Mohammed Ali1, Brian Corneil2, Aaron Camp1
1 University of Sydney, Sydney Medical School, Australia
2 University of Western Ontario, Canada
Purpose: The vestibular evoked myogenic potential (VEMP) is a technique used to assess vestibular function. Conventionally, cervical VEMPs (cVEMPs) are obtained from the sternocleidomastoid (SCM) muscle of the neck. Recent work has shown that splenius capitis (SPL) is also a robust target for measuring the cVEMP in young healthy subjects. It remains unclear however, if SPL-cVEMPs are also useful targets for assessment in older or patient populations.
Methods: Here, we used surface electromyography to measure cVEMPs from young subjects (mean age 21.9 ± 2.1; n=13), older subjects (64.8 ± 6.1; n=14), and age matched Parkinson’s disease (PD) patients (68.7 ± 6.5; n=6) in two positions: the clinical posture and simple seated head turns.
Results: The incidence of both clinical and seated SCM-cVEMPs diminished significantly in older and PD patients in comparison with young subjects (p <0.01 and 0.001 respectively). In contrast, no differences were found in SPL-cVEMPs across groups. Importantly, SPL-cVEMPs were present significantly more often than seated SCM-cVEMPs in PD patients (p = 0.003), highlighting the utility of this muscle target in clinical populations. cVEMP parameters including peak amplitude and latencies were comparable across groups.
Conclusions: These findings show that the SPL is a reliable target for cVEMP measurements in older and clinical patients. Further, the changes in SCM cVEMP in older populations are not replicated in the SPL. Together these data hint at the potential of SPL as a means to limit false positive cVEMP measurements in clinical populations.
PP1-106 - Suppression head impulse paradigm in normal adults: values and parameters
7. Clinical Testing for Vestibular Function
Feiyun Chen1
Qing Zhang1, Caiqin Wu1, Yanfei Chen1, Min Xu1, Yuzhong Zhang1, Zichen Chen1
1 Department of Otorhinolaryngology, Head and Neck Surgery,The 2nd Affiliated Hospital, Xi’an Jiaotong University School of Medicine
Purpose: To study the normal range of parameters of suppression head impulse paradigm (SHIMP) in normal Chinese adult population.
Methods: 30 healthy adults were selected as subjects and all of them underwent conventional SHIMP examination. Parameters provided by the video head pulse software include gain, the latency and the peak velocity of saccades were calculated.
Results: All the subjects were elicited anti-compensatory saccades in SHIMP test. The normal values of left and right VOR gain were 1.01, 1.10 in HIMP and 0.93, 1.01 in SHIMP respectively. The left and right saccade latency were 201.1± 50.8ms, 187± 42.9ms and the peak saccadic velocity were 302.7 ± 58.5 degree/s, 291.5 ± 46.5 degree/s in SHIMP. No significant difference could be found between bilateral ears (p>0.05).
Conclusions: SHIMP is a promising examination which could be used to evaluate anti-compensatory saccades and provide us further information on VOR function.
PP1-107 - Systemic Aminoglycosides-Induced Vestibulotoxicity in Humans
7. Clinical Testing for Vestibular Function
Ruth Van Hecke
1
Vincent Van Rompaey2, Floris L. Wuyts3, Laura Leyssens1, Leen Maes4
1 Ghent University, Department of Speech, Language and Hearing Sciences, Belgium
2 Antwerp University Hospital, Department of Otorhinolaryngology and Head & Neck Surgery, Belgium / University of Antwerp, Faculty of Medicine and Health Sciences, Belgium
3 Antwerp University Research center for Equilibrium and Aerospace (AUREA), Department of Otorhinolaryngology and Head & Neck Surgery, Belgium / University of Antwerp, Department of Biomedical Physics, Belgium
4 Ghent University, Department of Speech, Language and Hearing Sciences, Belgium / Ghent University Hospital, Department of Otorhinolaryngology, Belgium
Purpose: This systematic review aimed to investigate the prevalence and characteristics of vestibular adverse effects of aminoglycoside (AG) therapy in humans and to analyze objective vestibular tests for the detection of AG-induced vestibulotoxicity.
Methods: PubMed, Cochrane Database, Web of Science, and reference lists of all included studies were screened by two independent researchers. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were followed. Studies were included according to preset inclusion criteria and reported outcomes of studies evaluating vestibular function using one or more objective vestibular function tests in adults and children after systemic AG administration. The methodological quality of each study was assessed using the quality assessment tool for quantitative studies. Interrater reliability was established using Cohen’s Kappa.
Results: Twenty-seven studies were included, with the vast majority showing AG-induced vestibulotoxic side effects, ranging from 0 to 60%. Most studies reported AG-induced abnormalities by caloric and rotatory testing, whereas only a few studies reported using video Head Impulse Test and vestibular evoked myogenic potential testing.
Conclusions: Because type I hair cells (particularly of the semicircular canals) are more susceptible to ototoxicity, video Head Impulse Test and vestibular evoked myogenic potential testing seem more promising for the early detection of vestibulotoxicity than caloric and rotatory testing. Prospective studies using an extensive vestibular test battery are needed to further characterize the impact of AGs on the different vestibular end organs and to identify the most sensitive vestibular technique for the early detection of vestibulotoxicity.
PP1-108 - The analysis of the value ofspontaneous nystagmus in peripheral vestibular hypofunction.
7. Clinical Testing for Vestibular Function
lin peng
1
chen taisheng1, wang wei1, xu kaixu1, Li Shanshan1, wen chao1, liu qiang1
1 Tianjin First Center Hospital, Otorhinolaryngology Head and Neck Surgery, China
Purpose: To study the characteristics and clinical value of peripheral vestibular dysfunction.
Methods: 98 cases of acute unilateral vestibular peripheral vertigo patients were studied. The characteristics of SN, the relationship between SN and course of disease, DP and UW were analyzed According to the course.
Results: There were 62 patients with SN and 36 without SN out of 98 cases accounting for 63.3% and 36.7% respectively.SN was within intensity range of 0.5°/s 20.4 °/s and had negative correlation with the disease duration(r=-0.365 P=0.04). SN was divided into 3 degrees according to its intensity, with median duration of disease course were 10d,5d and 3d respectively. The result of the caloric test were the followingunilateral weakness 45 cases72.6%with 7 cases having the direction of SN towards the weakness side and 38 cases pointing towards the opposite direction; bilateral weakness 9 cases14.5% and normal 8 cases12.9%. There were no relationship between the intensity of SN and UW value r=-0.051, P=0.692.The UW value of patients with SN (47.5 ± 22.5% was compared to the group without SN29.9±18.8%.
Conclusions: The intensity of SN in patients with acute unilateral vestibular peripheral vertigo majority was moderate and severe. Intensity with the course of the disease gradually weakened or change the direction, The degree of vestibular injury was higher than those without SN.
PP1-109 - The diagnostic value of the bone-conduction cervical vestibular evoked myogenic potentials (cVEMP)
7. Clinical Testing for Vestibular Function
Morgana Sluydts
1
Catherine Blaivie1, Andrzej Zarowski1, Erwin Offeciers1, Thomas Somers1, Joost van Dinther1, Robby Vanspauwen1
1 ENT Department, Sint-Augustinus Hospital Antwerp, European Institute for ORL-HNS, Antwerp, Belgium
Purpose: Defining the value of bone-conduction cervical vestibular evoked myogenic potential (BC VEMP) in patients with conductive hearing loss.
Methods: Both normative and patient data was obtained for air- and bone-conduction cervical VEMP (AC and BC VEMP, respectively). Tone bursts of 500 Hz (2-2-2 ms, repetition rate: 5.1 Hz) were delivered through insert earphones (130 dB sound pressure level (dB pSPL)) and with a B71 bone vibrator attached to an additional amplifier increasing the gain up to 20 dB (137 dB peak SPL (dB pSPL)), for AC VEMP and BC VEMP, respectively.
Results: A response rate of 100% was obtained for both AC and BC VEMP in the healthy participants. Several parameters were significantly different between the two stimulation methods (p13 latency (p = 0.010; Z = -2,6; meanAC = 14,4 ms (standard deviation (SDAC) = 0.70 ms); meanBC = 14,0 ms (SDBC = 0.84 ms)), p13-n23 amplitude (p = 0.005; Z = -2,8; meanAC = 419,7 µV (SDAC = 171,80 µV); meanBC = 299,9 µV (SDBC = 128,33 µV)), and corrected amplitude (p = 0.002; Z = -3,2; meanAC = 2,2 (SDAC = 0,59); meanBC = 1,5 (SDBC = 0,57))). In the patient group, a significant air-bone gap was detected in 13 patients (13/143, 9%). Six of them had normal BC VEMPs (4/6, 67%). Some specific cases of comorbidity were found.
Conclusions: The standard B71 bone vibrator attached to an additional amplifier was capable of bypassing the conductive hearing loss in 67% of the cases. Therefore, BC VEMP should be considered whenever an ABG is present (even when falsely induced by a semicircular canal dehiscence (SCD) or when co-existing with one).
PP1-110 - The Role of Predictability in the Suppression Head Impulse Test
7. Clinical Testing for Vestibular Function
Eduardo Martin-Sanz
1
Jorge Rey-Martinez2, Jonathan Esteban1, Ricardo Sanz1
1 Universidad Europea de Madrid, University Hospital of Getafe, Madrid , Spain
2 ENT Department, Hospital Universitario Donostia, San Sebastián, Spain
Purpose: To analyze the main characteristics of the early saccadic responses in participants according to three SHIMP protocols,depending on the predictability of the head impulse.
Methods: A prospective cohort non-randomized study was designed. For the SHIMP protocol, recorded with the ICS Impulse ver. 4.0® (Otometrics , Denmark) vHIT device, three different algorithms were performed: “predictable,” “less predictable,” and “unpredictable” depending on the target’s predictability. A mathematical method was developed to analyze the responses.
Results: In cohort 1, 52 participants were included in “predictable” SHIMP protocol. In cohort 2, 60 patients were included for the “less predictable” and 35 patients for the “unpredictable” SHIMP protocol. The participants made more early saccades when instructed to perform the “predictable” paradigm compared with the “less predictable” paradigm (p < 0.001). The less predictable protocol did not reveal any significant difference when compared with the unpredictable protocol (p = 0.189). For the latency of the first saccade, there was statistical difference between the “unpredictable” and “predictable” protocols (p < 0.001) and between the “less predictable” and “predictable” protocols (p< 0.001). Finally, we did not find any relationship between the horizontal vestibulo-ocular reflex (hVOR) gain and the latency of the saccades.
Conclusions: Our findings offer evidence regarding the influence of predictability on the latency of the SHIMP saccadic responses, suggesting that early saccades are probably caused by a conditioned response of the participant. The lack of relationship between the hVOR gain and the latency of the saccades suggests that the predictive behavior that caused the early eye saccades are independent of the vestibular function.
PP1-111 - The use of virtual reality in the assessment BPPV-related otolithic dysfunction a pilot study.
7. Clinical Testing for Vestibular Function
Maria Vartanyan
1
Stephen O’Leary2, Kumiko Orimoto3, Sukanya Rajiv1, Adrian Dragovic1, Fiona Hill1, Keitebe Leareng1, Nichola Baker1, Elodie Chiarovano4, Hamish MacDougall4, David Szmulewicz5
1 The Royal Victorian Eye and Ear Hospital, Balance Disorders and Ataxia Service, Australia
2 The Royal Victorian Eye and Ear Hospital, Deprtment of Otology, Australia; The University of Melbourne, Department of Otolaryngology, Australia
3 The Royal Victorian Eye and Ear Hospital, Deprtment of Otology, Australia; The University of Melbourne, Department of Otolaryngology, Australia
4 The University of Sydney, School of Psychology
5 The Royal Victorian Eye and Ear Hospital, Balance Disorders and Ataxia Service, Australia; Florey Institute of Neuroscience and Mental Health, Australia; Cerebellar Ataxia Clinic, Alfred Hospital, Au
Purpose: Residual dizziness (RD) following successful canalith repositioning manoeuvre (CRM) for benign paroxysmal positional vertigo (BPPV) is relatively common yet poorly understood. One possible mechanism is otolithic dysfunction (OD) – concurrent and/or following CRM. There is an uncertainty in the literature whether abnormality of subjective visual vertical testing (SVV) is associated with RD.
Methods: A new bedside quantitative test – virtual reality-based SVV (VR-SVV), was employed. VR-SVV was measured before and after CRM, and then weekly, up to 4 visits. In addition to this, symptoms were recorded. Control data was obtained. Ethical approval was obtained from the Eye and Ear Hospital’s Human Research Ethics Committee.
Results: 33 patients (33-85yo, 22F, 11M) with BPPV and 19 controls (22-56 yo, 8F, 11M) were assessed. 16/33 (48%) complained of either concurrent or RD. The VR-SVV was abnormal in 18/82 (23%) testing episodes. There was a significant correlation between dizziness and the presence of abnormal VR-SVV (p<0.05). In the RD cohort, there was also a significant correlation between abnormal VR-SVV value and RD (p<0.05). The incidence of false-positive VR-SVV results was similar in both the study and the control groups.
Conclusions: This pilot study indicates that VR-SVV is a promising new tool for the research assessment and clinical diagnosis of BPPV-related dizziness, but a larger sample size will supply a more definitive result.
PP1-112 - Updated screening tests of balance for vestibular disorders
7. Clinical Testing for Vestibular Function
Helen Cohen
1
Ajitkumar Mulavara2, Brian Peters2, Jasmine Stitz3, Haleh Sangi-Haghpeykar1, Susan Williams1, Jacob Bloomberg4
1 Baylor College of Medicine
2 KBRwyle Laboratories
3 University of Applied Sciences/ Upper Austria
4 NASA/ Johnson Space Center
Purpose: We previously studied one manner of testing tandem walking and the Romberg on foam with head still and head moving in pitch. We found moderate ROC values, sensitivity and specificity. The goal of this study was to approach population norms with larger samples.
Methods: We tested Romberg on foam with eyes closed/ feet together: head still, and moving in yaw and pitch at 0.3 Hz. The sample included controls, n= 355; and patients with vestibular disorders, n=140. We also tested subjects on tandem walking with eyes closed (controls, n = 291; patients, n=92); the total number of correct steps was counted, on three consecutive trials. Logistic regression was performed for estimation of area under the curve (AUC), where cut offs for best combinations of sensitivity/specificity were determined. P <.05 was considered significant.
Results: Durations of Romberg trials with head moving in controls were significantly shorter than head still trials but did not differ from each other; trial durations decreased gradually and significantly with age. ROC values were moderate, depending on the exact cut of the age range, but were approximately 0.75. On Tandem Walking subjects improved slightly on the second trial but fatigued on the third trial. ROC values were moderately high, better for younger subjects, < age 60, than subjects > age 60: ROC=0.8 younger subjects but ROC=0.72 older subjects.
Conclusions: Romberg head still and moving trials were useful. The first trial of tandem walking is a good indicator of performance.These screening tests are moderately useful for screening patients with vestibular disorders.
PP1-113 - Variacin del dhi en pacientes de rehabilitacion vestibular, independientemente de la patologa
7. Clinical Testing for Vestibular Function
Javier Martin Previgliano
1
Lucia Corrionero1, Valerio Hinojosa1, Rafael Suarez1, Nerina Coria1, Christiane Ponteville1, Myrian Nuñez1
1 Centro Martin Previgliano
Purpose: The evaluation of the vestibular system is somewhat complex because of whats happens with technological advances, the possibility of changing the reflection of the speaker of the eye with a high-speed camara attached to the glasses, register changes in this reflection. Serving this method as an effective diagnosis for pathologies of this system.
Methods: Retrospective, longitudinal, descriptive and observational study in which a video test of cephalic impulse was performed in patients with acute vestibular neuritis in which the variation of the pre and post treatment result was analyzed, takin into account the age and laterality.
Results: The average of the gain of all the groups increased, bein the group of 10-24 the most significant with a variation of 10 point 0.66 in differntial contrast with that of 75-100 which was only 0.1 point of gain 0,62.
Conclusions: The low response to the treatment of the group of 75-100 years could be explained due to a physiological decrease in the functioning of the RVO, which could be presenting a new plateau
PP1-114 - Variation of v-hit in patients with vestibular neuritis pre and post treatment.
7. Clinical Testing for Vestibular Function
Javier Martin Previgliano
1
Lucia Corrionero1, Valerio Hinojosa1, Rafael Suarez1, Nerina Coria1, Christiane Ponteville1, Myrian Nuñez1
1 Centro Martin Previgliano
Purpose: The evaluation of vestibular system is semewhat complex with technological advances, it is possible to evaluate the vestibular reflex with an accelerometer and a high speed camera attached to a pair of glasses, allowing to record alteratons in this reflex. Serving this as an affective diagnostic method for pathologies of this system.
Methods: Retrospective, longitudinal, descriptive and observational study in which cephalic impulse video test was performed in patients with acute vestibular neuritis, analyzing the variation of pre and post treatment result.
Results: The results gave the mayor an incidenceon on the right channels that on the sides at the front and at the and of this there is a difference of 0,005 point of gain favor of the left side and only 0,03 point for the right.
Conclusions: The v-hit is shown as an important tool not only as a diagnostic method but also as an important element for the pathological follow-up of the pathology and its response to vestibular kinesic treatment. The result show an effective variation to the treatment for both sides. With a better response to the treatmnet of the left channels with respect to the right.
PP1-115 - VEMP characteristics of vestibular paroxysm
7. Clinical Testing for Vestibular Function
Guiliang Zheng
1
Jingchun He1, Shuna Li1, Min Shen1, Jun Yang1
1 Department of Otolaryngology and Head and Neck Surgery, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine
Purpose: Vestibular paroxysmia (VP) is a syndrome consisting of frequent short episodes of vertigo, which is attributed to neurovascular cross-compression (NVCC). Although VP was described by Jannetta and colleagues more than 30 years ago, there are few researches of VEMP features on vestibular function of VP. The purpose of this study is to identify the VEMP manifestations of vestibular paroxysmal.
Methods: A total of 19 patients were included in the study from January 2014 to December 2016. All patients underwent pure tone audiometry, tympanometry, caloric test , VEMP examination and and 3.0T MRI examination. Summarize the correlation between the VEMP features and MRI findings in the patients with paroxysmal vestibular.
Results: There were 8 males and 11 females were included in the study and followed up with a median age of 43 years old. In all the 19 cases, 17 cases were confirmed by cross-oppression of vestibular nerves and blood vessels with MRI examination. Among these cases, 5 were bilateral and 12 were unilateral. Abnormal caloric tests were foundin 5 cases and high frequency hearing loss were found in 8 cases. VEMP abnormalities were found in 14 patients(7 cases latent period prolonged, 5 cases unilateral absent responses; 2cases bilateral absent responses).
Conclusions: The abnormal expression of VEMP is close to that of vascular and nerve intersecting compression by MRI test. The abnormal rate of VEMP was significantly higher than that of t caloric tests and pure tone audiometry.VEMP examination can be used as detection means in the evaluation of vestibular function in VP.
PP1-116 - VEMP using a new low frequency bone conduction transducer
7. Clinical Testing for Vestibular Function
Bo Håkansson
1
Karl-Johan Fredén Jansson1, Tomas Tengstrand2, Leif Johannsen3, Måns Eeg-Olofsson4, Cristina Rigato1, Elisabeth Dahlström4, Sabine Reinfeldt1
1 Department of Electrical Engineering, Chalmers University of Technology, Gothenburg, Sweden
2 Department of audiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
3 Ortofon A/S, DK-4900 Nakskov, Denmark
4 Department of Otolaryngology, Head and Neck Surgery, Sahlgrenska Academy, Gothenburg, Sweden
Purpose: A new prototype bone conduction transducer, called B250 which has an improved low frequency response, is evaluated in vestibular evoked myogenic potential (VEMP) investigations. The B250 offers a possibility to measure VEMP at a lower frequency than possible with a standard B71/B81 audiometric transducer and at a lower sound stimulation level than needed using air conduction (AC) stimulation. The aim is to compare cervical (cVEMP) and ocular (oVEMP) responses with focus on stimuli hearing levels required to reach threshold using bone conduction (BC) versus AC stimulation.
Methods: Three subjects from our research group with normal vestibular function were investigated in a pilot study. BC stimulation was applied to the mastoids in cVEMP, and both mastoid and forehead in oVEMP investigations.
Results: BC stimulation was found to reach VEMP thresholds at considerably lower hearing levels than in AC stimulation (39 dB lower oVEMP threshold at 250 Hz). Clinically useful cVEMP and oVEMP responses were obtained at 250 Hz for mastoid stimulation with the B250 transducer in all subjects. These results also means tha VEMP investigations are possible also for patients having a pronounced bone conduction hearing loss. If forehead stimulation is provided, this study indicate that a more powerful vibration output may be needed.
Conclusions: Hearing sound levels required to evoke cVEMP and oVEMP were found to be considerably lower and more pleasant with BC stimulation than with AC. Clinically useful cVEMP and oVEMP responses were reached in all subjects with a new low frequency transducer at 250 Hz when applied to the mastoid.
PP1-117 - Vestibular function in children with congenital cytomegalovirus infection: A two-year follow-up
7. Clinical Testing for Vestibular Function
Cleo Dhondt
1
Ingeborg Dhooge2, Lotte Rombaut3, Els De Leenheer2, Helen Van Hoecke2, Leen Maes4
1 Faculty of Medicine and Health Sciences, Department of Otorhinolaryngology, Ghent University, Ghent, Belgium
2 Faculty of Medicine and Health Sciences, Department of Otorhinolaryngology, Ghent University; Department of Oto-rhino-laryngology, Ghent University Hospital, Ghent, Belgium
3 Department of Oto-rhino-laryngology, Ghent University Hospital, Ghent, Belgium
4 Department of Oto-rhino-laryngology, Ghent University Hospital; Faculty of Medicine and Health Sciences, Department of Speech, Language and Hearing Sciences, Ghent University, Ghent, Belgium
Purpose: Congenital cytomegalovirus (cCMV) infection is the main cause of non-hereditary sensorineural hearing loss (SNHL) in children. The alleged underlying mechanism, cCMV-related labyrinthitis, can also affect the vestibular system which can have important consequences on the motor development in children. Therefore, longitudinal vestibular follow-up in all cCMV-infected children was initiated in our hospital in June 2016.
Methods: The follow-up protocol consists of a baseline-testing around 6 and 12 months, followed by an annual re-evaluation until the age of 6 years, with the video Head Impulse Test, rotatory test and cervical Vestibular Evoked Myogenic Potential test. Since 2016, 58 cCMV-patients were enrolled for follow-up, of which 37 already had more than one, and 12 had more than two follow-up examinations.
Results: Of all cCMV-patients included in this study, 28 were asymptomatic and 30 symptomatic. Within the latter group, 12 had SNHL (7 bilateral, 5 unilateral). Apparent saccular and horizontal canal dysfunction was determined in 33% (4/12) of this hearing-impaired group (3 bilateral, 1 unilateral). The vestibular dysfunction was present at first examination in 3 and delayed in onset in 1 of these children. Progression of the vestibular deficit during the course of the follow-up was found in 1 patient. Up until now, no apparent vestibular deficits were confirmed in asymptomatic cCMV-patients or normal-hearing symptomatic cCMV-patients.
Conclusions: The results of this study show that symptomatic cCMV-infected children with hearing loss are most at risk for vestibular deficits. As these can be delayed in onset and/or progressive, longitudinal follow-up is recommended.
PP1-118 - Vestibular Infant Screening-Flanders (VIS-Flanders): the start of an exciting project.
7. Clinical Testing for Vestibular Function
Leen Maes
1
Sarie Martens2, Cleo Dhondt3, Marieke Sucaet2, Saartje Vanaudenaerde4, Lotte Rombaut4, Ingeborg Dhooge5
1 Ghent University, Department of Speech, Language and Hearing Sciences, Belgium / Ghent University Hospital, Department of Oto-rhino-laryngology, Belgium
2 Ghent University, Department of Speech, Language and Hearing Sciences, Belgium
3 Ghent University, Department of Otorhinolaryngology, Belgium
4 Ghent University Hospital, Department of Oto-rhino-laryngology, Belgium
5 Ghent University, Department of Otorhinolaryngology, Belgium / Ghent University Hospital, Department of Oto-rhino-laryngology, Belgium
Purpose: A vestibular dysfunction can compromise a child’s development on many levels. Because of the anatomical relationship between the auditory and vestibular end organs, hearing-impaired children are considered a vulnerable group. Although research demonstrated that 20 to 85% of all hearing-impaired children have some kind of vestibular dysfunction, vestibular testing is not yet established in their multidisciplinary approach. Consequently, vestibular deficits often go unnoticed, giving rise to associated disorders such as delayed motor development, behavioral disorders, etc. The purpose of this project is the implementation of a vestibular screening test in order to guarantee a basic vestibular assessment in hearing-impaired children at a young age and enable early referral for rehabilitation.
Methods: VIS-Flanders is financially supported by the Research Foundation – Flanders, with participation of all reference centres responsible for the neonatal hearing screening program in Flanders. Each child with a confirmed hearing loss will be referred for a vestibular screening at the age of 6 months. Being short and child-friendly, feasible from a young age and highly correlated with motor performance and static balance, the cervical vestibular evoked myogenic potential test was elected for this purpose.
Results: Data collection in all reference centres will start in June 2018. In this presentation/poster, an overview will be provided of all the steps that will be undertaken during this 4-year project.
Conclusions: A standard vestibular screening for all hearing-impaired children should lead to early identification of vestibular deficits and subsequent prompt referral for vestibular rehabilitation, in order to limit its impact in developing children.
PP1-119 - Vestibular testing results in a world-famous extreme tightrope walker
7. Clinical Testing for Vestibular Function
Alexander Andrea Tarnutzer
1
Fausto Romano2, Nina Feddermann-Demont2, Urs Scheifele2, Giovanni Bertolini2, Jürg Kesselring3, Dominik Straumann2
1 University Hospital Zurich, Department of Neurology, Switzerland
2 University Hospital Zurich, Department of Neurology and Swiss Concussion Center, Schulthess Clinic, Zurich, Switzerland
3 Valens Rehabilitation Center, Valens, Switzerland
Purpose: For accurate and precise navigation in space and postural stability, multisensory (vestibular, proprioceptive, visual) input is centrally integrated and weighted based on its reliability to continuously update the internal estimate of direction of gravity. In a world-famous 53-year-old male tightrope walker we sought to examine both peripheral and central vestibular functions and examined to which extent such extraordinary performance is reflected in our recordings.
Methods: Both semicircular canal (caloric irrigation, rotatory-chair testing, video-head-impulse testing of all six canals, dynamic visual acuity) and otolith (subjective visual vertical, fundus photography, ocular/cervical vestibular-evoked myogenic-potentials (oVEMPs/cVEMPs)) test batteries were obtained. In addition, static and dynamic posturography and video-oculography (smooth-pursuit eye-movements, saccades, nystagmus testing) were performed. The subject’s results were compared to normative values.
Results: Semicircular canal testing was normal except for a slightly reduced response on right-sided caloric irrigation (26% asymmetry ratio, cut-off = 25%), whereas on otolith testing a significant asymmetry ratio of oVEMP-amplitudes was confirmed using two devices from different companies (37% and 53% weaker on the left side, cut-off = 30%). Bone-conducted cVEMP-amplitudes were marginally reduced on both sides. Posturography, video-oculography and subjective-visual-vertical testing results were all within normal range.
Conclusions: Extraordinary balance skills in this professional tightrope walker contrasted with significant peripheral-vestibular (otolithic) deficits. This emphasizes the role of central computational mechanisms, optimizing multisensory input signals and fully compensating for vestibular asymmetries in this case.
PP1-120 - VHIT and the influence of daily use of spectacles to correct a refractive error
7. Clinical Testing for Vestibular Function
Tessa Van Dooren
1
Floor Lucieer1, Miranda Janssen2, Raymond van de Berg1, Herman Kingma1
1 Division of Balance Disorders, Department of Otorhinolaryngology and Head and Neck Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
2 Department of ENT/Audiology, School for Mental Health and Neuroscience (MHENS), Maastricht University Medical Center, Maastricht, The Netherlands.
Purpose: To determine the influence of daily use of spectacles to correct a refractive error, on the VOR gain measured with the video head impulse test (vHIT).
Methods: This prospective study enrolled subjects between 18 and 80 years old with and without a refractive error. Subjects were classified into three groups: (1) contact lenses, (2) spectacles and (3) control group without visual impairment. Exclusion criteria comprised ophthalmic pathology, history of vestibular disorders and alternated use of spectacles and contact lenses in daily life. One examiner performed all vHIT’s under standardized circumstances using the EyeSeeCam system. This system calculated the horizontal VOR-gain for rightward and leftward head rotations separately.
Results: No statistically significant difference was found in VOR gain between the control group (n=16), spectacles group (n=48) and contact lenses group (n=15) (p = 0.111). Both the spectacles group and contact lenses group showed no statistically significant difference in VOR gain between different refractive error, for rightwards (p= 0.071) and leftwards (p= 0.716) head rotations. There was no statistical significant difference in VOR gain between testing monocularly or binocularly (p = 0.132) and between testing with or without wearing contact lenses (p = 0.800).
Conclusions: In this study VOR gain was not influenced by wearing corrective spectacles or contact lenses on a daily basis. Based on this study, no corrective measures are necessary when performing the vHIT on subjects with a refractive error, regardless of the way of correction.
PP1-121 - vHIT using a smart phone.
7. Clinical Testing for Vestibular Function
Kazuhiro Kuroda
1
Tatsuaki Kuroda1, Toru Seo2
1 Kuroda Ent Clinic
2 Kinki University Faculty To Medicine,
Purpose: The features of the test are simpler, easier, and less discomfort than conventional caloric test.
Methods: We searched the appropriate machine which can examine vHIT.
Results: To examine vHIT , we decided using a high-speed camera built-in smartphone.
Conclusions: We show a prototype implement for examine vHIT.
PP1-122 - VVOR and VORS tests as a tool in the diagnosis of unilateral and bilateral vestibular hypofunction
7. Clinical Testing for Vestibular Function
Bernardo Ramos
1
Renato Cal2, Sergio Carmona3, Francisco Zuma e Maia4
1 MD, PhD; Professor of Otorhinolaryngology; Espirito Santo Federal University, Brazil
2 MD; Professor of Otorhinolaryngology; Para Federal University, Brazil
3 MD; Professor of Neurophysiology; National University of Rosario, Argentina
4 MD, PhD
Purpose: In clinical practice, exams such as video head impulse test (VHIT) and suppression head impulse paradigm (SHIMP) stimulates high frequency head movements so the visual and somatosensory system are somehow suppressed. In low frequencies two tests could be useful tools to vestibular assessment: VVOR (visually enhanced vestibular-ocular reflex) and VORS (Vestibulo-ocular reflex suppression). The aims of this study is to explain the eye movements typically found in VVOR and VORS tests in patients with unilateral and bilateral vestibular hypofunction.
Methods: Seven patients with unilateral vestibular hypofunction, two patients with bilateral vestibular hypofunction and ten patients without vestibular symptoms (control group) were analysed retrospectively according to the VVOR and VORS tests using an Otometrics ICS Impulse system.
Results: Patients with unilateral vestibular hypofunction exhibited catch up saccades beating to the healthy side when moved the head to the affected side in the VVOR test. Patients with bilateral vestibular hypofunction showed catch up saccades beating to the opposite side of the head movement. Patients with unilateral vestibular hypofunction showed in the VORS test cath-up saccades to the healthy side when moved the head to this side. Patients with bilateral vestibular hypofunction did not show catch up saccades during the head movement for both sides.
Conclusions: Our data suggest that VVOR and VORS tests exhibited the same findings as the VHIT and SHIMP tests in unilateral and bilateral vestibular hypofunction and contribute to confirm the peripheral etiology as well as the affected side.
PP1-123 - Assessment of horizontal semicircular canal after cochlear implantation by vHIT and caloric test
8. Cochlear Implant and Vestibular Function
Zeng Jie
1
HUANG hongming1, WANG xiaoqian1, WU peina1
1 guangdong general hospital
Purpose: The focus of this work is to investigate the function and characteristic of horizontal semicircular canals from patients after cochlear implantation (CI).
Methods: We retrospectively evaluated vestibular function of 18 patients (both side=4, single side=14) who were treated with CI surgery by using caloric test and video head impulse test. Three time points were recorded: 1 week before CI, 1 week after CI and 1 month after CI. We also observed the parameters of the unilateral weakness (UW), slow phase velocity (SPV) and video head impulse test gain (vHIT-G).
Results: In caloric test, the SPV (cold water; hot water (mean±SD)) of the implant-ear were 1 week before CI (10.36±8.01°/s;14.77±14.24°/s), 1 week after CI (6.45±7.52°/s;5.14±4.67°/s) and 1 month after CI (6.05±3.86°/s;6.27±4.17°/s), respectively. The SPV in the groups of 1 week and 1 month after CI were both significantly decreased than the group of 1 week before CI. (p0.05).
In video head impulse test, the vHIT-G (mean±SD) of the implant-ear were 1 week before CI (0.73±0.33), 1 week after CI (0.65±0.32) and 1 month after CI (0.71±0.36), and no significant difference of vHIT-G were found between the groups of before CI and after CI (1 week and 1 month) (p>0.05). In addition, we did not find any correlation between the symptom of vertigo and age, gender, implanted ear and the outcome of vestibular test.
Conclusions: Our results suggest that CI can affect the function of horizontal semicircular canal, and the combination of video head impulse test and caloric test leads to complementarities.
PP1-124 - Assessment of the otolith function of the cochlear implant surgery using eccentric rotation test
8. Cochlear Implant and Vestibular Function
Tomoko Okumura
1
Takao Imai1, Yumi Ohta1, Yasumitsu Takimoto2, Takashi Sato1, Yasuhiro Osaki1, Yukiko Hanada1, Kazuya Ohata1, Yoshiyuki Ozono1, Ryusuke Imai1, Ryohei Oya1, Takefumi Kamakura3, Noriaki Takeda4, Hidenori Inohara1
1 Department of Otorhinolaryngology-Head and Neck Surgery, Osaka University Graduate School of Medicine
2 Department of Otorhinolaryngology, Osaka Police Hospita
3 Department of Otorhinolaryngology, Osaka Medical Center and Research Institute for Maternal and Child Health, Osaka, Japan
4 Department of Otorhinolaryngology-Head and Neck Surgery, Tokushima University Graduate School of Medicine, Tokushima, Japan
Purpose: To evaluate the effects of cochlear implant surgery on otolith function.
Methods: We evaluated 12 patients with sensorineural hearing loss or congenital deafness who underwent unilateral cochlear implantation (CI). To assess the otolith function, we use vestibule-ocular reflex during eccentric rotation (ER). When a patient is rotated while displaced from the axis of rotation during ER, the vestibulo-ocular reflex (VOR) caused by the utricle (linear VOR; lVOR) is induced. All patients sat on a chair at three different positions: on the axis (center rotation, CR), at 90cm behind the axis (nose-in ER, NI-ER) and at 90cm in front of the axis (nose-out ER, NO-ER) and were rotated sinusoidally. We judged that patients’ utricle function was normal when their VOR gain during NI-ER was higher and that during NO-ER was lower than during CR. Ocular vestibular evoked myogenic potential (VEMP, oVEMP) test and cervical VEMP (cVEMP) test were also performed before and 4 weeks after surgery.
Results: The VEMPs on the operated side decreased or disappeared after CI, the abnormal VEMPs rates were 33.3% and 58.3%. 7 of 8 patients whose ER response was normal before CI showed also normal ER response after CI.
Conclusions: Disappearance and impairment of oVEMPs could be observed after CI. However, the response of ER didn’t change before and after CI. This study shows the effect on the otolith function of cochlear implant is not severe enough to influence the lVOR failure induced by utricle during ER.
PP1-125 - Correlation between hearing and vestibular function preservation after cochlear implantation
8. Cochlear Implant and Vestibular Function
Seong-Cheon Bae
1
You-Ree Shin1, Kyoung-Ray Moon1, Hye-Jin Lim1, Kwang Sun Lee1, Chong Sun Kim1, Young-Myoung Chun1
1 Soree Ear Clinic, Seoul, Korea, republic of
Purpose: In general, vestibular function after cochlear implant(CI) is known to worsen, But recently, there are several reports about preserving vestibular function after soft CI surgery. So, we reviewed our data about hearing preservation and vestibular function preservation
Methods: We reviewed 29 cases of adult CI patients. We applied the calculating method of hearing preservation rate from consensus on a hearing preservation classification system (Acta Otolaryngol Suppl. 2013;(564):3-13). And we grouped HP group (HP rate>26%) and non-HP group(HP rate<25%). We yielded maximum slow phase velocity (SPV) and canal paresis (CP) of caloric test. We defined SPV preservation rate as post-op. SPV/ pre-op. SPV (%) and we divided into caloric preservation group as results of pre-op. and post-op. canal paresis values. We evaluated correlation between HP rate and caloric test values.
Results: There were 21 patients in HP group and 8 patients in non-HP group. SPV preservation rate was an average of 62.12 % in the HP group and the non- HP group was 49.15 %. And the result of correlation analysis showed that there was no correlation (Sphearman’s Rho=0.203 p=0.292) In addition, in caloric preservation group, there were 17 patients (81.0%) in the HP group and 2 patients (25.0%) in non-HP group. There were significant differences at HP and caloric preservation groups. (Chi square test, P = 0.009)
Conclusions: Hearing preservation rate and SPV preservation rate showed low correlation rate. But, distribution of hearing preservation group and caloric preservation group showed significant correlation. So, there is some correlation between hearing and vestibular preservation after CI.
PP1-126 - Effects of Cochlear Implantation on Visual, Postural and Haptic Verticality Perceptions
8. Cochlear Implant and Vestibular Function
Camila Barros
1
Fernando Massa1, Arielle Casseta1, Suleimy Mazin2, Andreia Oliveira1, Eduardo Massuda1, Miguel Hyppolito1, Taiza Santos-Pontelli2
1 Department of Ophthalmology, Otorhinolaryngology, and Head and Neck Surgery, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, São Paulo, Brazil.
2 Department of Neuroscience and Behavior Sciences, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, São Paulo, Brazil.
Purpose: To investigate the effects of cochlear implantation (CI) on verticality perceptions and dizziness related disability in adults with sensorineural hearing loss (SNHL) and to analyze the correlation between verticality perceptions and disability in this population.
Methods: Patients with SNHL eligible for CI were recruited. Evaluation protocol was composed by Dizziness Handicap Inventory (DHI), evaluation of subjective postural vertical (SPV) and subjective haptic vertical (SHV) in roll and pitch planes and subjective visual vertical (SVV) in the roll plane before CI surgery (T0), immediately after the first activation of the speech processor (T1), and 6 months after the surgery (T2). We analyzed verticality perceptions in numerical and absolute values.
Results: Participants included 21 adults (39.6±13 years). At T1 in relation to T0 and T2, there were significant increases of SPV in absolute values (T0-T1: p=0.04; T1-T2: p=0.007) and DHI scores (T0-T1: p=0.001; T1-T2: p=0.002). There was a decrease of SHV in the roll plane in absolute values from T1 to T2 (p=0.002). With Bonferroni correction, we found positive correlations of DHI with absolute values of SVV (r=0.37; p=0.005), SPV in the roll plane (r=0.37; p=0.005), and SPV in the pitch plane (r=0.42; p=0.001).
Conclusions: The CI reduced SHV misperception 6 months after surgery. The activation of speech processor produced a transient increase in SPV misperception that was restored 6 months after surgery. Disability is related to SVV and SPV in patients with SNHL submitted to CI. These results highlight the relevance of the assessment of verticality perceptions in this population.
PP1-127 - Intra-cochlear Figuration of Implant Electrodes using Synchrotron Phase Contrast Imaging
8. Cochlear Implant and Vestibular Function
Sumit Agrawal1
Nadine Schart-Moren2, Hanif M. Ladak3,
Helge Rask-Andersen2, Hao Li2
1 Western University, Department of Otolaryngology-Head and Neck Surgery, Canada
2 Uppsala University Hospital, Department of Surgical Sciences, Head and Neck Surgery Section of Otolaryngology, Department of Otolaryngology, Sweden
3 Western University, Department of Medical Biophysics and Department of Electrical and Computer Engineering, Canada
Purpose: Cochlear implant has been used for many years to restore hearing in patients, however its electrode positioning in the cochlea is less studied.
Methods: We used synchrotron-phase contrast imaging (SR-PCI) and volume-rendering software with bony and soft tissue algorithms to evaluate the positioning of electrodes after cadaveric cochlear implantation. Micro-CT with 3D rendering was used for comparison.
Results: Micro-CT displayed the round window and osseous spiral laminae while SR-PCI allowed reproduction of the soft tissues such as the basilar membrane, spiral ligament, Reissner and round window membranes. Artefact-free reproduction, figuration and topographic localization of the electrodes’ metallic constituents and the silicon casing could be assessed.
Conclusions: The positioning of cochlear implant electrode is important as it may interfere with normal physiological function.
PP1-128 - Long term effects of cochlear implantation on vestibular evoked myogenic potentials
8. Cochlear Implant and Vestibular Function
Qing Zhang
1
Yong Xu1, Yuzhong Zhang1, Zichen Chen1, Juan Hu1, Feiyun Chen1, Peng Han1, Ying Chen1, Min Xu1
1 Department of Otorhinolaryngology, Head and Neck Surgery,The 2nd Affiliated Hospital, Xi’an Jiaotong University School of Medicine,Xi’an City (710004), Shaanxi Province, P.R.China.
Purpose: To oberserve relatively long-term effect of cochlear implantation on vestibular otolithic end organs.
Methods: 17 patients (17 ears) underwent cochlear implants in our department from February, 2013 to October, 2015 were selected as the patient group. Both cervical vestibular evoked myogenic potentials (cVEMP) and ocular vestibular evoked myogenic potential (oVEMP) were performed pre- and post-operatively. The data before and after surgery were collected and compared between each other.
Results: Before cochlear implantation, cVEMP and oVEMP were elicited in 59% and 53% of all ears respectively. After surgery, the response rates of cVEMP and oVEMP were decreased to 24% and 12% (whatever CI device on or off), and waveform parameters changed.
Conclusions: Our results suggest that cochlear implantation may have some effects on the performance of the vestibule otolithic end organs.
PP1-129 - Long-term evaluation of the vestibular function after cochlear implantation(CI) in children
8. Cochlear Implant and Vestibular Function
Dominique Vibert
1
Martin Kompis1, Georgios Mantokoudis1, Marco Caversaccio1
1 Dept of Otorhinolaryngology, Head & Neck Surgery, Inselspital, University of Bern, Switzerland
Purpose: Long-term evaluation of vestibular function of CI -patients implanted during childhood
Methods: 49 patients (18 females;31 males), aged from 7-34 years (mean=15.89) were included into our study. CI Implantation was performed on both sides (n=31), on right side (n=10), on left side (n=8); children were implanted between ages of 0.7 to 15.5 years (mean=5). Deafness was congenital (n=37), consequential to meningitis (n=2), skull fracture (n=1), perinatal CMV infection (n=1), ototoxic drugs (n=1). The etiology remained unknown within 7 patients. Vestibular function was measured with a time delay of 3 to 22 years (mean: 11) after CI,including VNG, v-HIT, c-VEMPS.
Results: Nine out of patients (18%) were symptomatic. Three patients complained of recurrent transient vertigo episodes at the adult age with either normal vestibular function (n=1), bilateral hyporeflexia (n=1) or unilateral areflexia to the side of delayed endolymphatic hydrops (n=1). Three patients complained of dizziness in darkness with bilateral areflexia (confirmed by calorics/vHT/cVEMP) before CI (meningitis: n=1;perinatal CMV: n=1;unknown etiology:n=1). Dizziness was central in origin after medulloblastoma excision (n=1). Vestibular neuritis with hyporeflexia, contralateral to CI was diagnosed within two patients. Among the 40 asymptomatic patients (82%), vestibular function was normal (n=16), decreased bilaterally (n=4), unilaterally (n=18; right side (n=8), left side (n=10)). Results were not interpretable because of lack of collaboration (n=2).
Conclusions: This first long-term evaluation in CI-children pointed out that 82% have no vestibular symptoms 3-22 years after CI. Vestibular function depends first of the etiology of the inner ear disease: it is particularly true in case of bilateral vestibular loss.
PP1-130 - The Effect of Cochlear Implant on Postural Control
8. Cochlear Implant and Vestibular Function
FAZIL ARDIC
1
FUNDA TUMKAYA1, ALEV ATIGAN1, FUSUN ARDIC1
1 Pamukkale University
Purpose: Some patients are having balance problems after cochlear implant surgery. There are contradictory reports about the effect of implant on postural control. While cochlear implant is working, an electrical current is continuously stimulating the cochlear nerve which is in close proximity with vestibular ganglion and nerve. This stimulation may contribute to vestibular signals to the central system. Our purpose is to investigate if this stimulation have any effect on postural control.
Methods: Eighteen adult patients who had unilateral cochlear implantation ages between 21 and 80 were included. Postural stability measurements were done by Biodex Balance System. Three preprogrammed main tests and their 9 subtests were applied. Postural stability, fall index, sensory integration were calculated. All tests were done in four conditions; implant off(1), implant on(2), implant on music on(3) and implant off again(4).
Results: Six male and 12 female patients were tested. Mean age was 49.9±18.42. When patients were tested, average postural stability overall score were measured 3.66±2.23, 3.33±2.23, 2.8±1.64, 3.16±1.69 according to first, second, third and fourth conditions consecutively. Fall index were calculated as 3.12±2.04, 2.58±1.61, 3.22±2.08, 2.98±1.5 consecutively. The change in the sensory organization test composite score was observed as 1.6±0.44, 1.79±0.51, 1.88±0.72, 1.97±0.67. There are statistically significant differences in some parameters. If the group divided with a cut off point age 50, this difference became more prominent.
Conclusions: Cochlear implant effects the vestibular system in some patients and current flowing through the cochlear nerve may have a positive effect on postural control.
PP1-131 - A questionnaire for the patient with benign paroxysmal positional vertigo: a pilot study
9. Epidemiology
Akihito Nakanishi
1
Naoko Ueda1, Masatsugu Asai1, Hideo Shojaku1
1 University of Toyama
Purpose: The questionnaire items to diagnose the patient with benign paroxysmal positional vertigo (BPPV) were investigated.
Methods: The questionnaire of 77 items consisted of age, gender, past history, characteristics of vertigo/dizziness including cause, lasting time, intensity, frequency, quality and associated symptoms, and usually existing symptom was made in Department of Otolaryngology, University of Toyama. From January 2015 to June 2017, 392 patients with vertigo/dizziness filled out our questionnaire. All patients were diagnosed by two specialized neurotologists based on the diagnostic criteria drafted by the Japan Society for Equilibrium Research. The results were analyzed by multivariate logistic regression to investigate the relationship between questionnaire items and BPPV.
Results: Twenty-three of 392 patients (5.8%) were diagnosed as BPPV. BPPV was detected by the combination of our questionnaire items with a specificity of 99% and a sensitivity of 73%, where mild attack of vertigo, tinnitus, attacks when reclining the head and lying down were included.
Conclusions: The combination of our questionnaire items might be useful for diagnosing BPPV.
PP1-132 - Epidemiology of acute isolated vertigo in an italian emergency department: a retrospective study
9. Epidemiology
Claudio Fantino
1
Luca Dutto2, Giulio Varrone3, Luca Ambrogio4, Maria Federica Grasso4, Raffaele Vitiello1, Mauro Giraudo2, Giuseppe Lauria2
1 Department of Otorhinolaryngology S.Croce e Carle General Hospital Cuneo, Italy
2 Department of Emergency Medicine S.Croce e Carle General Hospital Cuneo, Italy
3 Faculty of Medicine, University of Turin, Italy
4 Department of Neurology S.Croce e Carle General Hospital Cuneo Italy
Purpose: To evaluate epidemiology, etiology and use of resources on patients with a complaint of acute isolated vertigo (AIV) presenting in a Northwestern Italian Emergency Department (ED).
Methods: A retrospective study of patients older than 16ys old presenting to the ED from January 1st to December 31st 2015 was made. Incidence of AIV as main presenting symptom and etiologies were registered. Rate of admission and disposition were analyzed. Use of head CT scan was registered and its accuracy in diagnosing central nervous causes was calculated.
Results: During the whole period of the study AIV accounted for 1,3% (1.021/77.939) of all visits. Women were more often involved (58.4%). The mean age of the study population was 58.7 years. Central neurological diseases accounted for only 6.4% of AIV, while for 36% of patients an otorhinolaryngoiatric diagnosis was made. 146 patients (14.3%) needed to be admitted in hospital. Neurology and Emergency ones were the more involved departments for admitted patients. In 480 patients a head CT scan was requested and in only 13 (2.71%) it was diagnostic.
Conclusions: AIV is a frequent symptom in ED. Central nervous diseases represent a minimal but significant cause of AIV. The study confirm the low accuracy of head CT scan in finding central nervous etiologies.
PP1-133 - Multicenter databanking in management of dizzy patients first results from the DizzyNet registry
9. Epidemiology
Eva Grill
1
Sandra Becker-Bense2, Thomas Brandt3, Steffen Huebinger4, Doreen Huppert3, Ralf Strobl4, Andreas Zwergal2, Nese Celebisoy5
1 Institute of Medical Information Processing, Biometry and Epidemiology (IBE), Faculty of Medicine, Ludwig-Maximilians-Universität München, Germany, German Center for Vertigo and Balance Disorders, University Hospital, Ludwig-Maximilians-Universität München
2 German Center for Vertigo and Balance Disorders, University Hospital, Ludwig-Maximilians-Universität München, Department of Neurology, University Hospital, Ludwig-Maximilians-Universität München
3 German Center for Vertigo and Balance Disorders, University Hospital, Ludwig-Maximilians-Universität München, Institute for Clinical Neurosciences, University Hospital, Ludwig-Maximilians-Universität
4 Institute of Medical Information Processing, Biometry and Epidemiology (IBE), Faculty of Medicine, Ludwig-Maximilians-Universität München, Germany, German Center for Vertigo and Balance Disorders, Uni
5 Department of Neurology, Ege University, Izmir, Turkey
Purpose: Comprehensive phenotypical data across countries is needed to understand the determinants, prognosis and consequences of vestibular disease. The project is a data repository for the members of the European DizzyNet. We report results from a pilot study using data from Turkey and Germany.
Methods: The pilot study included a convenience sample of patients aged 18 or above referred to the Ege University Medical School Hospital, Izmir, Turkey, and the German Center for German Center for Vertigo and Balance Disorders, University on Munich, Germany, with symptoms of vertigo or dizziness. Health-related quality of life was assessed with the EQ5-D and the Dizziness Handicap Inventory (DHI). To obtain comparable groups we matched data from the two study centres for age, sex and diagnosis by propensity score.
Results: We included 80 adult patients, 40 from each study centre (60% female, mean age 54.1, SD 12.4). Matching was successful. Vestibular migraine (34%) was the most frequent diagnosis, followed by benign paroxysmal positional vertigo (29%) and Menière’s disease (12%). Clinical signs and symptoms were comparable in both countries. Patients from Turkey were more likely to report headaches (65% vs. 32%) and to show gait unsteadiness (51% vs. 5%). Patients from Germany reported significantly higher quality of life and lower values of the DHI score and all DHI subscales.
Conclusions: Sharing data facilitates research, enhances translation from basic science into clinical applications, and increases transparency. The registry is a first step to data sharing in vestibular research across Europe.
PP1-134 - The prevalence of persistent tinnitus and dizziness in an elderly population in southern Taiwan
9. Epidemiology
Ning-Chia Chang
1
Chia-Yen Dai2, Wen-Yi Lin3, Hua-Ling Yang4, Hsun-Mo Wang5, Chen-Yu Chien6, Kuen-Yao Ho6
1 Kaohsiung Medical University/Kaohsiung Municipal Hsiao-Kang Hospital, Department of Otolaryngology, Kaohsiung, Taiwan
2 Kaohsiung Medical University, Department of Internal Medicine, Kaohsiung, Taiwan
3 Kaohsiung Municipal Hsiao-Kang Hospital, Health Management Center, Kaohsiung, Taiwan
4 Kaohsiung Medical University Hospital, Department of Internal Medicine, Kaohsiung, Taiwan
5 Kaohsiung Municipal Hsiao-Kang Hospital, Department of Otolaryngology, Kaohsiung, Taiwan
6 Kaohsiung Medical University, Department of Otolaryngology, Kaohsiung, Taiwan
Purpose: This study was to investigate the prevalence of persistent tinnitus and chronic/recurrent dizziness in an elderly population and to analyze the associations of certain comorbidities with tinnitus and dizziness in southern Taiwan.
Methods: This was a community-based study performed in a metropolitan hospital.Volunteers ages ≥ 65 years were recruited, and hearing tests were performed. The pure tone average (PTA) and hearing handicap score (HH) were calculated. Questionnaires about the histories of hypertension, diabetes, and symptoms of tinnitus and dizziness were administered. The associations of sex, age, PTA/HH, body mass index (BMI), hypertension, diabetes, and metabolic syndrome (MetS) with tinnitus and dizziness were analyzed.
Results: A total of 597 participants, with 322 (53.9%) men and 275 (46.1%) women, were included. The prevalence of persistent tinnitus and chronic/recurrent dizziness was 32.0% and 24.1%, respectively. Age, BMI, hypertension, diabetes, and MetS were not associated with tinnitus or dizziness. Hearing impairment was associated with tinnitus. Women and those with fasting glucose levels <100 mg/dL (5.55 mmol/L) were more likely to have symptoms of dizziness.
Conclusions: Persistent tinnitus and dizziness were common in an elderly population in southern Taiwan. These findings may help develop strategies to promote the quality of life in an elderly population.
PP1-135 - Cognitive impairment in persistent postural-perceptual dizziness: working vs. non-working patients
10. Functional and Psychiatric Vestibular Disorders
Jackie Micklewright1
Jeffrey Staab
2
1 Healthwise Behavioral Health & Wellness, Maple Grove, Minnesota, USA
2 Mayo Clinic, Rochester, Minnesota, USA
Purpose: Patients with chronic vestibular disorders often complain of cognitive difficulties that interfere with job performance. Previous data showed that patients with bilateral peripheral vestibular loss had reduced performance on spatial memory tests that correlated with bilateral hippocampal atrophy on neuroimaging. Patients with unilateral peripheral vestibular loss had more nuanced deficits on spatial tasks and neuroimaging. The aim of this pilot study was to exam cognitive performance in patients with persistent postural-perceptual dizziness (PPPD), who often report difficulties with attention, memory, and concentration in the workplace, even when not afflicted with uncompensated structural vestibular deficits.
Methods: In this retrospective investigation, we identified 13 patients who received a primary diagnosis of PPPD after undergoing multidisciplinary neuro-otologic evaluations for chronic dizziness and separately completing neuropsychological testing for cognitive complaints. None had uncompensated otologic deficits or neurologic/psychiatric disorders that explained their cognitive symptoms.
Results: Working (N=5) and non-working (N=8) patients had similar mean intelligence scores, but the group that was not actively employed had relative deficiencies on tests of auditory working memory (Letter Number Sequencing) and executive functioning, specifically cognitive flexibility affecting visual processing speed, scanning, and tracking (Trail Making B) and response inhibition (Stroop Color Word Tests). In contrast, group performances did not differ on simpler tests of memory (Digit Span, Word List Retention) or executive functioning (Trail Making A).
Conclusions: Our pilot results suggest that PPPD may be associated with cognitive impairments that interfere with productive employment and that cognitive performance may be linked to functional as well as structural alterations in the vestibular system.
PP1-136 - Dr
10. Functional and Psychiatric Vestibular Disorders
Peixia Wu
1
Yan Hu2
1 Eye & ENT Hospital of Fudan University, Shanghai, China
2 School of Nursing, Fudan University, Shanghai, China
Purpose: To translate and examine the psychometric properties of the Vestibular Activities and Participation questionnaire in Chinese language (VAP-C).
Methods: A standard “forward-backward” procedure was adopted to translate VAP into Chinese version. The VAP-C was administered to a convenience sample of 121 patients complaining of dizziness due to peripheral vestibular dysfunctions. Internal consistency was estimated using Cronbach’s alpha and test-retest reliability examined by intraclass correlation coefficients (ICCs). Validity was confirmed using convergent and a principal components factor analysis with Varimax rotation. Convergent was assessed by exploring correlations with VAP-C and Dizziness Handicap Inventory (DHI) dimensions and total score.
Results: Minor revisions were made during translation to ensure content equivalence and to better suit a Chinese population. The Cronbach’s alpha coefficients for the two subscales of VAP-C were 0.83 and 0.91, respectively, suggesting good internal consistency. ICCs for the two subscales were greater than 0.75 and thus determined good reproducibility. Factor analysis confirmed two-factor solution which is as hypothesized. Two factors showed clearly item matching with all items loaded > 0.5 on either factor one or factor two. The VAP-C was significantly correlated with the DHI (rho=0.61-0.73), demonstrating a convergent construct validity.
Conclusions: The VAP-C shows evidence of reliability and construct validity, which can be considered a reliable measurement for evaluating the impact of the vestibular disorder on patients’ activities and participation.
PP1-137 - Influence of Visual and Vestibular Hypersensitivity on Depersonalization/Derealization in Dizziness
10. Functional and Psychiatric Vestibular Disorders
Michel Toupet
1
Christian Van Nechel2, Charlotte Hautefort3, Sylvie Heuschen4, Ulla Duquesne2, Anne Cassoulet4, Alexis Bozorg Grayeli1
1 Dijon University Hospital, Otolaryngology Department,France
2 Dizzy Care Clinic, Brussels, Belgium
3 Lariboisière UNiversity Hospital, Otolaryngology Department,France
4 Centre d’Explorations Fonctionnelles Otoneurologiques, France
Purpose: The aim of this study was to investigate the relation between visual and vestibular hypersensitivity and Depersonalization/Derealization symptoms in patients with chronic dizziness.
Methods: 319 adult patients with chronic dizziness for more than 3 months (214 females and 105 males, mean age: 58 years, range: 13-90) were included in this prospective cross-sectional study. Patients underwent a complete audio-vestibular workup and 3 auto questionnaires: Hospital Anxiety and Depression (HAD), Depersonalization/Derealization Inventory (DDI), and an in-house questionnaire (Dizziness in Daily Activity, DDA) assessing 9 activities with a score ranging from 0 (no difficulty) to 10 (maximal discomfort) and 11 (avoidance) to detect patients with visual and vestibular hypersensitivity (VVH, a score > 41 corresponding to mean + 1 standard deviation).
Results: DDI scores were higher in case of VVH (6.9 ± 6.79, n=55 versus 4.2 ± 4.81, n=256 without VVH, p<0.001, unpaired t-test), migraine (6.1 ± 6.40, n=110 versus 4.0 ± 4.42, n=208no migraine, p< 0.001, unpaired t-test) and motion sickness (6.8 ± 5.93, n=41 versus 4.4 ± 5.11, n=277 no motion sickness, p< 0.01, unpaired t-test). Women scored DDI higher than men (5.1 ± 5.42, n=213 versus 3.9 ± 4.91, n=105 respectively, p<0.05, unpaired t-test). DDI scores were also related to depression and anxiety. DDI score was also higher during spells than during the basal state.
Conclusions: During chronic dizziness, depersonalization/derealization symptoms seem to be related to anxiety and depression. Moreover, they were prominent in women, in those with visual and vestibular hypersensitivity, migraine, and motion sickness.
PP1-138 - Persistent Postural-Perceptual Dizziness in the Light of New Diagnostic Criteria
10. Functional and Psychiatric Vestibular Disorders
Sinisa Maslovara
1
Silva Butkovic Soldo2, Anamarija Sestak3
1 Department of Otorhinolaryngology and Maxillofacial Surgery, Medical Faculty, University of Osijek, J. Huttlera 4, Osijek 31 000, Croatia
2 Department of Neurology, Medical Faculty, University of Osijek, J. Huttlera 4, Osijek 31 000, Croatia
3 Department of Otolaryngology, County General and Veterans Hospital Vukovar, Zupanijska 35, 32000 Vukovar, Croatia
Purpose: The Behavioral Subcommittee of the Bárány Society Committee for Classification of Vestibular Disorders recently established the diagnostic criteria for persistent postural-perceptive dizziness (PPPD), including most elements of the functional dizziness described earlier, but not anxiety and depression, some of their prominent features. This study aims to determine how significant the degree of anxiety and depression of PPPD patients is when compared to the patients with other causes of dizziness.
Methods: The study was conducted on 78 patients, 39 (50%) of whom suffer from PPPD, and of a control group consisting of the same number of patients with other types of dizziness. Upon arrival, all the patients filled out the DHI and HADS questionnaire and were subjected to a VNG and VEMP examination.
Results: The DHI showed severe disability in 48 (62%) patients, slightly more in the group of other dizziness (72%). The HADS indicated pathological depression in 18 (23%) patients and borderline amounted to 41 (53%), slightly more common in patients with other dizziness (62%). A mild anxiety level was similar in both groups of patients. Laboratory tests did not show significant differences between groups.
Conclusions: Our research showed that the majority of patients in both groups experienced mild anxiety, while those with the pathological degree were somewhat more represented in the PPPD group. Depression was more expressed in the group of other dizziness and has manifested itself in a mild form in nearly half of all patients.
PP1-139 - Selective serotonin reuptake inhibitor (SSRI) and vestibular function
10. Functional and Psychiatric Vestibular Disorders
Kensuke Kiyomizu
1
Kensuke Kiyomizu2, Keiji MATSUDA2, Koji Torihara2, Hironori Fujii3, Hiroaki Shimogori4, Ryuichiro Takeda5, Hideki Funahashi6, Yasushi Ishida6, Kensei Yoshida1, Tetsuya Tono2
1 Department of Psychiatry, Yoshida Hospital, Japan
2 Department of Otorhinolaryngology, Head & Neck Surgery, Faculty of Medicine, University of Miyazaki, Japan
3 Department of Otorhinolaryngology, University of Yamaguchi, Japan
4 Department of Otorhinolaryngology, Yamaguchi Rosai Hospital, Japan
5 Department of Healthcare And Security Center, University of Miyazaki, Japan
6 Department of Clinical Neuroscience, Faculty of Medicine, University of Miyazaki, Japan
Purpose: It is well known that selective serotonin reuptake inhibitor (SSRI) is effective for patients with dizziness and depression. However, there are only few papers about vestibular function for those patients. We therefore performed vestibular ocular reflex tests in rotation (VOR tests) and utilized Dizziness Handicap Inventory (DHI) questionnaire before and after SSRI therapy.
Methods: Out of 135 depressive patients in 1089 patients with dizziness in our psychiatric hospital, the subjects were 13 patients (4 men, 9 women) (mean age, 58.9 years) experiencing dizziness and depression with the following conditions (SSRI group); 1)regular treatment including anti-vertigenous drugs, physical therapy, minor tranquilizer or sleep medications were not effective, 2)non-acute phase, 3)non-prescription of antidepressants, 4)signature of consent form approved by the ethics committee in University of Yamaguchi. VOR tests were performed using video-oculograph (Nystamo21 type 2, IRN-2, Morita Manufacturing corporation, Tokyo). Eye movements were monitored using an infrared eye camera installed in the goggles. Head movements were transduced to d.c. signals (range 0-5 V) by a small angular velocity sensor.
Results: After about 4 weeks of using additional SSRI treatment, DHI scores were improved significantly (66.2-30.0). In VOR tests, DP% scores (vestibular function) were improved significantly (23.2-9.57).
Conclusions: These results of the present clinical research suggested that SSRI might have some effects which improved the vestibular function in patients with dizziness and depression.
PP1-140 - Sensory Organization Test Profile for Patients with Persistent Postural-Perceptual Dizziness
10. Functional and Psychiatric Vestibular Disorders
Neil Shepard
1
Devin McCaslin2, Jeffrey Staab3, Scott Eggers4
1 Educational & Clinical Consultation, Private practice, USA
2 Mayo Clinic, ENT, USA
3 Mayo Clinic, Psychiatry, USA
4 Mayo Clinic, Neurology, USA
Purpose: Söhsten, et al. (2016) reported significant differences between patients diagnosed with Persistent Postural-Perceptual Dizziness (PPPD) (n=20) versus normal subjects (n=15) and peripheral vestibular patients (n=15) on conditions 1-6 of the Sensory Organization Test (SOT) of the EquiTest ™. This study expanded on the number of subjects and investigated the efficacy of the SOT pattern in the identification of PPPD.
Methods: Retrospective equilibrium scores on SOT with the Bertec ™ equipment were compared for 96 PPPD patients, 72 unilateral vestibular hypofunction patients & 53 patients with both unilateral hypofunction and PPPD via Wilcoxon/Kruskal-Wallis test. The diagnostic groups were stratified by age group. Logistic regressions with ROC analysis were used to investigate the SOT pattern for identification of PPPD patients.
Results: Significantly (p<.05) poorer performance for the PPPD patients on the easier conditions (1-3) were noted with the differences on the more difficult conditions (4-6) most likely an age effect. Logistic regressions demonstrate that the values of the equilibrium scores do have a relationship with the diagnostic categories via ChiSq (p< 0.05) for each of the SOT conditions. However, ROC analysis showed that predicting the diagnostic category from the SOT pattern was typically poor (area under the curves from. 46-.77).
Conclusions: This work shows a pattern of performance on SOT for the pure PPPD or the PPPD with unilateral hypofunction patients that is significantly different from that of unilateral vestibular hypofunction patients with the performance poorer on the easier conditions. However, while distinctive it cannot be used as a biomarker for the PPPD patient.
PP1-141 - Structure Changes of Superior longitudinal fasciculus in Persistent Postural-Perceptual Dizziness
10. Functional and Psychiatric Vestibular Disorders
Kangzhi Li
1
Xu Yang1
1 Department of Neurology, Aerospace Center Hospital, Peking University Aerospace School of Clinical Medicine, Beijing,China.
Purpose: To investigate the changes of white matter fibers in patients with persistent postural-perceptual dizziness (PPPD).
Methods: 7 patients (three males and four females) diagnosed with PPPD were enrolled. All patients underwent detailed medical history acquisition; meanwhile, cranial MRI, peripheral vestibular function evaluation, internal medicine and laboratory tests were performed to exclude other chronic dizziness lesions. SVDSCVS, DHI score were performed to assess the patient’s symptoms. The patients confirmed PPPD were further scanned by Diffusion Tensor Imaging (DTI). Fractional anisotropy (FA) and mean diffusivity (MD) were calculated, and then voxel-based analysis (VBA) was performed to investigate the changes of white matter fibers in patients with PPPD.
Results: (1) All patients were right-handed. The average age was 51.71±13.41 years old. The mean duration of the disease was 7.77 ± 7.60 years. The average SVDS score was 9.86 ± 6.04. The average CVS score was 5.57 ± 3.25. The DHI score was 51.29 ± 11.09. (2) The FA values of the right superior longitudinal fasciculus in PPPD patients were significantly lower than in healthy subjects (P <0.001, uncorrected). The MD values of white matter fibers in the postcentral gyrus were significantly lower than healthy subjects (P < 0.05, FDR corrected).
Conclusions: The changes of white matter fibers in superior longitudinal fasciculus, postcentral gyrus in PPPD patients suggest that the transmission of information from the PIVC area to the postcentral gyrus and precentral gyrus may be abnormal and may be related to the persistent symptoms of dizziness and postural instability.
PP1-142 - A study on auto-scoring algorithm for balance assessment
11. Gait, Posture, and Locomotion
Kyu-Sung Kim
1
Yeon-wook Kim2, Kyung-Lim Joa3, Han-Young Jung3, Sangmin Lee2
1 Department of Otolaryngology, Inha University, Incheon, Korea
2 Department of electronic engineering, Inha university, Incheon, Korea
3 Department of Rehabilitation Medicine, Inha University, Incheon, Korea
Purpose: We studied scoring algorithm for Berg balance scale assessment using inertial measurement unit and machine learning methods.
Methods: Thirty-five patients with brain disease, aged 50 to 80 years, participated in the experiment. The IMU sensors were placed on their forehead, back, left wrist, right wrist, left ankle, and right ankle. The data of 3-axis acceleration roll, yaw, and pitch from each IMU were measured and the sampling rate of all signal was 100Hz. Support vector machine and multi-layer perceptron were compared as machine learning techniques. According to each motion of BBS task, different data from 6 IMUs was selected.
Results: Average classification accuracy of SVM is 92% and MLP is 86%. It is higher performance than other prior paper about BBS scoring algorithm.
Conclusions: In this study, we can confirmed the possibility of automation of Bergs balance scale. Objective quantification can be measured through the improvement of scoring algorithm.
PP1-143 - Assessment of vestibular compensation in static posturography tests.
11. Gait, Posture, and Locomotion
Ewa Zamyslowska-Szmytke
1
Magdalena Janc2, Mariola Sliwinska-Kowalska3
1 Nofer Institute of Occupational Medicine, Audiology and Phoniatrics Clinic, Balance Disorders Unit.
2 1Nofer Institute of Occupational Medicine, Audiology and Phoniatrics Clinic, Balance Disorders Unit.
3 1Nofer Institute of Occupational Medicine, Audiology and Phoniatrics Clinic.
Purpose: Static posturography is usually falsely negative in compensated vestibular disorders. Adding head movements may increase clinical utility of the examination for diagnosing subjects with vestibular pathology.
Methods: Results of standard static posturography and static posturography with added head movements (HS-posturography, 30° side to side, 1 Hz) were analysed. Four tests were performed and then repeated with head movements on: a firm surface with eyes open (1) and closed (2), a foam with eyes open (3) and closed (4). Four groups participated in the study: BPPV - 44 patients (mean age 58 SD 11.7, range 27-87 years) without canal paresis in calorics, UC - 55 patients with uncompensated unilateral weakness (mean age 55 SD 13.6 , range 29-83 years); C- 46 patients (56 SD 14.8, range 25-85 years) with compensated unilateral weakness and 55 healthy control (50 SD 15.5, range 24-78 years).
Results: The results of standard and HS posturographies were different depending on the group tested. BPPV revealed higher mean body sways than control in one standard test (2) and two HS tests (1, 4), the C group shows the differences in one standard test (2) and in all HS tests. All tests in the UC group were higher than in control. There were statistically significant sway differences between UC and C groups.
Conclusions: Adding head movements to static posturography may improve its clinical utility in diagnosing of vestibular patients.
PP1-144 - Balance disorder of patients with Mnire’s disease: assessing with posturography and gait analysis
11. Gait, Posture, and Locomotion
Peng Liu
1
Yongkang Ou1, Qiuhong Huang1
1 Department of Otolaryngology-HNS, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, 107 Yanjiang west Rd, Guangzhou, 510120, China.
Purpose: Here, we aimed to investigate static and dynamic unequlibrium ability of patients with Ménière’s disease (MD) applying static posturography and three-dimensional gait analysis.
Methods: Thirty-two MD patients were collected in this study, along with 15 normal controls. A sensory organization test (SOT) and three-dimensional gait analysis were used to quantify the patients’ static and dynamic ability to maintain balance.
Results: Compared with the normal subjects, MD patients showed significantly lower vestibular weight (68.82 ± 21.04) and visual weight (80.94 ± 18.28) in the medial-lateral direction in SOT test (p < 0.05). In the anterior-posterior direction, the vestibular score (64.19 ± 19.02) was significantly decreased (p < 0.05). During the gait analysis, the MD patients showed slower walking speed (2.15 ± 0.69 km/h) and higher cadence (0.86 ± 0.12 steps/min). The normalized stride width in the MD patients (79.25 ± 9.50 %) was larger than that in the controls (p < 0.05). In patients with unilateral vestibular hypofunction, we found that the stance phase lasted significantly longer on the lesion side (53.19 ±6.57 % vs. 48.49 ± 7.82 % on the healthy side, p < 0.05).
Conclusions: Both in static posture control and dynamic continuous walking, MD patients exhibited poor stability in the medial-lateral direction. Especially, patients with unilateral vestibular hypofunction are inclined to enhance somatosensory feedback by extending stance phase in lesion side.
PP1-145 - Correlations between multiplane vHIT and balance control after acute unilateral vestibular deficit.
11. Gait, Posture, and Locomotion
John H.J. Allum
1
Flurin Honegger1
1 Department of ORL, University of Basel Hospital, Basel, Switzerland
Purpose: Clinically, balance deficits in the pitch and roll planes at onset of an acute unilateral peripheral vestibular deficit (aUPVD) are assumed to be correlated with deficits in vestibular ocular reflex (VOR) responses. Previous studies have shown that correlations for lateral canal (yaw) VOR responses are weak. However, stronger correlations with balance measures should be expected for anterior and posterior canal responses as these indicate deficits in roll and pitch. Therefore, we investigated this expectation.
Methods: 27 patients were examined at aUPVD onset. 3D VOR vHIT measures in each canal plane were converted to roll and pitch response asymmetries, and then correlated with balance measures. To measure balance control during stance and gait, body-worn gyroscopes mounted at lumbar 1-3 recorded trunk angular velocity in roll and pitch.
Results: Average vHIT yaw VOR response gain asymmetry (35.6±10.5) was greater than roll VOR asymmetry (14.6±10.5, p<0.05) and correlated (p=0.03). Average Pitch gain VOR asymmetry was considerably less (5.9±10.1). No significant correlations between VOR roll and pitch asymmetries and trunk sway were found for stance (R<0.25). In contrast several gait roll balance measures were significantly correlated with VOR roll asymmetry: walking 8 tandem steps (R=0.51), walking while pitching the head up and down (R=0.72), walking with eyes closed (R=0.59). No correlations were found with pitch asymmetry.
Conclusions: This is the first report to link roll balance control deficits with roll VOR deficits. This report emphasises the need to perform 3D vHIT to judge the effect of an aUPVD on balance control.
PP1-146 - Disordered gait pattern after craniocervical trauma a case study
11. Gait, Posture, and Locomotion
Helena Huhmar
1
Juha-Pekka Kulmala2, Jussi Nurminen2, Harri Piitulainen3, Juhani Partanen4, Lauri Soinne5
1 Biomedicum Scientific Programme, Biomedicum Helsinki, Helsinki, Finland
2 Motion Analysis Laboratory, Children’s Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
3 Department of Neuroscience and Biomedical Engineering, Aalto University School of Science, Espoo, Finland
4 Helsinki University Hospital, Dept. of Neurophysiology, Espoo, Finland
5 Helsinki University Hospital, Dept. of Neurology, Helsinki, Finland
Purpose: We analyzed gait and muscular activation patterns of an uncommon gait disorder patient with locomotor abnormality emerging after a craniocervical trauma. Our aim was to elucidate the sensorimotor mechanisms of the disorder.
Methods: A healthy 43-year-old farmer was attacked and tossed about by a raging bull. Immediately, he experienced inability to carry his head upright and maintain bipedal gait. Subsequent slow recovery was interrupted by spells of vertigo pushing him forwards and leftwards. Years after, he was victim to an electric shock, followed by increasing left-sided muscle tone. Within months, he developed a gait disorder manifesting in involuntary leftward stepping provoked by turning or rising up from a chair to walk. The gait disorder seemed dependent on the position of both head and trunk. His MRI findings were suggestive of a left-sided atlantoaxial subluxation.
We assessed his gait using 3D-motion analysis with electromyography recordings of the main lower extremity muscles.
Results: The patient had apparent difficulty in initiating gait and maintaining static standing balance. His gait was interrupted with hopping movements resembling reduplication of his left-pedal step. Especially soleus, gastrocnemius, and peroneal EMGs displayed rhythmic bursts of activity bilaterally throughout the main muscle activation, with approximately normal timing of the activation phase. Forward bending of spine enabled fairly normal gait, despite prevailing abnormal bursts.
Conclusions: The described unusual gait disorder, associated with traumatic craniocervical misalignment, is suggested to be due to abnormal propriospinal activation.
PP1-147 - Dissociated objective and subjective stability in the elderly due to postural anxiety
11. Gait, Posture, and Locomotion
Patricia Castro
1
Diego Kaski2, Marco Schieppati3, Michael Furman2, Qadeer Arshad2, Adolfo Bronstein2
1 (1) Neuro-otology Unit, Division of Brain Sciences, Charing Cross Hospital Campus, Imperial College London, London, UK. (2) Escuela de Fonoaudiología, Facultad de Medicina, Clínica Alemana Universidad del Desarrollo, Santiago, Chile.
2 Neuro-otology Unit, Division of Brain Sciences, Charing Cross Hospital Campus, Imperial College London, London, UK.
3 Department of Exercise & Sport Science, International University of Health, Exercise and Sports, LUNEX University, Differdange, Luxembourg
Purpose: Under static conditions, the subjective perception of instability correlates well with objective measures of postural sway. Here we investigate this correlation as a function of age and anxiety in dynamic challenging conditions.
Methods: 50 healthy participants (aged 18-83 years) stood upright on a moving platform. Six pseudo-random oscillatory stimuli of different magnitude, each lasting 30s, were delivered twice, with and without a fall-preventing harness (aimed at reducing task-related anxiety). We measured sway path, hip angular velocity, foot-lift counts and subjective instability and task-related anxiety.
Results: The subjective perception of stability accurately matched objective body sway, following a logarithmic function profile (r2=0.72, p<0.001). This function did not change significantly with age, harness or task presentation order (harness or no-harness first). A strong relationship was observed between the subjective measures of stability and task-related anxiety (r=0.812, p<0.001). Repetition of the task induced age-specific adaptive changes: anxiety decreased in the young but postural sway decreased in the old. This resulted in an uncoupling between change in anxiety and subjective instability in the young but not in the elderly. Higher anxiety levels were associated with increased subjective unsteadiness in the older subjects.
Conclusions: Subjects accurately rate their own instability during dynamic postural challenges, irrespective of age and actual fall risk. However, anxiety has greater influence upon the subjective perception of instability in the elderly. Our data suggest that anxiety contributes to “fear of falling” in the elderly. Wearing a harness does not influence subjective/objective postural stability, a useful finding for postural researchers
PP1-148 - Does the sensory organization test discriminate between athletes and non-athletes?
11. Gait, Posture, and Locomotion
Fausto Romano
1
Alessandra Ventura2, Karin Mani2, Dominik Straumann1, Giovanni Bertolini1, Nina Feddermann2
1 University of Zurich, Department of Neurology, Switzerland
2 Schulthess Clinic, Swiss Concussion Center, Switzerland
Purpose: Evidence in literature indicates that sports activities may contribute to enhanced postural stability in athletes. It has been suggested that practice of highly skilled movements that involve sensory systems for postural control leads to improvements in balance. Performing the Sensory Organization Test (SOT), a standard test for evaluating sensory interactions in balance control, we aim at investigating whether: (1)athletes have a more stable standing posture than non-athletes; (2)different postural strategies are used across different sports; (3)SOT can detect subtle balance changes.
Methods: 120 athletes (70 hockey, 20 football, 30 handball) and 20 non-athletes were recruited. SOT was performed using a computerized dynamic posturography system(EquiTest) to assess subjects’ ability to use visual, proprioceptive and vestibular cues for maintaining postural stability in upright stance. Specifically, 20 features were computed from COM and COP signals as measures of postural steadiness.
Results: Standard COM-based features provided by EquiTest did not show any significant difference between athletes and non-athletes, although they are commonly used to identify balance problem in elderly and vestibular patients. More surprising, no significant differences between athletes and non-athletes as well as among the different sports were detected using our CoP-based feature set.
Conclusions: Our negative findings suggest two possible explanations: (1)considering that the discriminatory ability of a test depends on task complexity, SOT is not challenging enough to differentiate between athletes and non-athletes; (2)the specific modalities of postural control developed within sports activities are not always transferable to the upright stance situations, as such abilities can be specific to a particular task.
Support:Schulthess Foundation.
PP1-149 - Effects of visuo-ocular state on vestibular-evoked behaviors during standing balance
11. Gait, Posture, and Locomotion
Emma Raat
1
Jean-Sebastien Blouin2, Johannes van der Steen1, Patrick Forbes1
1 Erasmus Medical Center, Neuroscience, the Netherlands
2 University of British Columbia, School of Kinesiology, Canada
Purpose: Vestibular signals are integrated with visual/somatosensory information, such that, when standing, removal of vision increases vestibular-evoked whole-body responses. This contrasts with the vestibulo-ocular reflex (VOR), whose efficacy decreases in absence of visual signals. The current study investigates differential modulatory effects of visuo-ocular states (i.e. eyes open/closed and light/darkness) on vestibular-evoked eye and balance responses.
Methods: Ten healthy subjects received electrical vestibular stimulation (0–20Hz,±5mA) while standing to evoke balance (force/EMG) and VOR responses during three conditions: eyes open in the light, eyes open in darkness, and eyes closed in darkness. Subjects were then exposed to repeated transitions between lights on-off conditions with eyes open, and eyes open-closed conditions in darkness. We estimated modulatory effects of visuo-ocular state by comparing vestibular-evoked muscle and VOR responses across conditions.
Results: Contrary to previous reports, we found no effect of visuo-ocular state on vestibular-evoked balance responses (p>0.05). VOR responses, in contrast, decreased significantly with lights off (~30%, p<0.05), and even further with eye closure (~80%, p<0.05). VOR responses with shorter latencies than turning lights on. When opening and closing the eyes, VOR responses were rapidly distorted by eye movements initiating prior to lid motion, but stabilized to expected levels shortly (1-2 sec) thereafter.
Conclusions: We demonstrate differential effects of visual signals and eye-state on the vestibular control of gaze stabilization and balance when standing. Shorter latencies in VOR modulation when removing vision may reflect the need for faster modulation to reduced sensory input, or alternatively, increased processing demand to re-integrate sensory signals when vision is returned.
PP1-150 - Evaluation of balance performance in vestibular loss patients using virtual reality system
11. Gait, Posture, and Locomotion
Qiwen Shen
1
Catherine de Waele2, Marius Gras3, Patrice Bendahan3, Georges Lamas4
1 Cognition and Action Group, CNRS UMR8257, University of Paris Descartes, Paris, France
2 Cognition and Action Group, CNRS UMR8257, University of Paris Descartes, Paris, France; ENT Department, Pitie Salpetriere Hospital, Paris, France
3 ESPHI, La Ciotat, France
4 ENT Department, Pitie Salpetriere Hospital, Paris, France
Purpose: This study is to evaluate the balance performance in vestibular loss patients by using a new visual perturbation system including virtual reality (VR), Wii Balance Board (WBB), rubber foam, and a wearable accelerometer for body sway parameter quantification.
Methods: 46 normal subjects and 27 patients suffering from unilateral vestibular loss were recruited. Subjects were instructed to stand on WBB plus foam, and to wear a goggle delivering VR image. Two visual conditions were assessed: stable visual world (VR0.0) and perturbed visual world (VR0.1). Each condition lasted for 25s. Subjects wore one 3D accelerometer attached on the site of the L5 vertebra. The balance performance was quantified by calculating the average “jerk” value at X, Y, and Z axis during the test. Patients who fell during the test were removed from “jerk” analysis.
Results: All normal subjects and patients completed VR0.0 without falling. No normal subjects fell at VR0.0, but 33% patients fell at this condition. At VR0.0, the average “jerk” in healthy subjects is 2.10±0.98 (min-max: 0.68-5.59), and in patients is 4.97±2.84 (min-max: 0.80-14.82). At VR0.1, the average “jerk” in normal subjects is 3.54±1.73 (min-max: 0.68-8.68), while in patients is 10.62±4.70 (min-max: 1.10-16.33).
Conclusions: The new visual perturbation system with WBB and foam, and VR allows clinicians to efficiently evaluate balance performance and visual dependency at clinical settings. The body sway parameter “jerk” successfully distinguished vestibular deficit patients from healthy subjects. This system may be used in rehabilitation program to follow the improvement of balance performance in patients with inefficient vestibular compensation.
PP1-151 - Influence of arteriosclerosis on balance function Data from Iwaki health promotion project
11. Gait, Posture, and Locomotion
Yuri Mitsuhashi
1
Shinichi Goto1, Akira Sasaki1, Atsushi Matsubara1
1 Hirosaki University School of Medicine, Otorhinolaryngology, Japan
Purpose: There are multiple factors that can deteriorate balance function. Vascular insufficiency to vestibule and the central nervous system is one of the causes of balance dysfunction. Therefore, to examine the relationship between vascular sclerosis and balance function, we conducted an epidemiological survey in a community-dwelling population in Japan.
Methods: We included volunteers who had participated in the Iwaki Health Promotion Project in 2015 and 2016. This project is performed every year, with the aim of improving health and longevity in the Iwaki district. In total, 1078 subjects (405 males, 673 females) were analyzed. We examined the brachial–ankle pulse wave velocity (baPWV), which is an objective index that quantifies arterial stiffness. We also analyzed static posturography using the path length to evaluate balance function. We assessed the effect of baPWV on the path length using multiple regression models.
Results: There was significant correlation between baPWV and the path length with eyes opened in males and with eyes opened and closed in females.
Conclusions: This study was targeted toward the general population, rather than patients experiencing dizziness, and demonstrated the correlation of baPWV and static posturography parameters. Herein, we suggested that the progression of vascular sclerosis is related to balance dysfunction.
PP1-152 - Postural control instability caused by virtual reality
11. Gait, Posture, and Locomotion
Eva Ekvall Hansson
1
Per-Anders Fransson2, Mitesh Patek3, Michéle Lundberg1, Hanna Jensen1, Fredrik Tjernström2, Måns Magnusson2
1 Lund University, Department of Health Sciences, Sweden
2 Lund University, Department of Clinical Sciences in Lund,Sweden.
3 Imperial College London, Division of Brain Sciences, United Kingdom
Purpose: To study possible adaptation of postural control to responses evoked by a virtual reality surrounding with provocative elements including possible gender effects.
Methods: Twenty healthy subjects participated in the study (10 females). A custom-built force platform was used to measure postural sway. The virtual reality stimulation comprised a VR movie containing a roller coaster like simulation of travelling on a railroad track situated in a mountainous terrain. Quiet stance was measured with eyes open and eyes closed. VR stimuli tests were performed 5 times with a three-minute rest between each of the runs. The torque variance values during the tests were analysed using repeated measures GLM ANOVA on log-transformed values.
Results: During VR perturbations, repeatedly watching the same movie significantly reduced the energy used (p<0.001). Females adapted more slowly to the VR stimuli as reflected by higher use of energy for all movement frequencies (p = 0.007) as well as for low frequency (p = 0.027) and high frequency (p = 0.026). Females adapted particularly more poorly in lateral direction to the VR stimuli as reflected by higher energy consumption in all frequencies (p < 0.001) as well as in high frequency movement energy (p = 0.005).
Conclusions: Being repeatedly exposed to the same virtual reality movie with provocative environment, initiated an adaptation that significantly reduced the energy used in postural control. This was true both for total energy as well as for high and low frequency movement responses. Females were found to adapt more slowly to a visual VR stimuli than male subjects.
PP1-153 - Postural instability according to the Virtual Reality program
11. Gait, Posture, and Locomotion
Sung Won CHAE
1
Hwibin IM1, Jae-Jun Song1, Yu-Young Park1, Tae-Hun Kim1
1 Korea University, College of Medicine, Guro Hospital
Purpose: Over the recent years the popularity and the market size of VR grew rapidly. It is absolutely necessary for the user to realize how much potentially dangerous VR is. The purpose of this study is to investigate the effect of VR images on balance in normal people.
Methods: This study was carried out on fifteen adults in their 20’s and 30’s who have normal sense of balance with SOT. Condition 1 and Condition 2 was performed once respectively, Condition 3 was performed three times while watching three different VR programs. The VR programs which were used for condition 3 tests were classified as mild-, moderate- and severe- image motion before the test. And then, the equilibrium score of SOT was analyzed to find the difference of each test.
Results: The MES of mild VR image of Condition 3 was 93.888, the moderate one was 92.422 and the severe one was 75.422. There was no difference in MES between the condition 1 and the mild and moderate VR image of Condition 3 (Paired T-test, p>0.05), but the MES of severe VR image of Condition 3 was statistically lower than Condition 1. In addition, the MES of severe VR image, which could feel heavy movement in 3-dimensional world, was lower than that of mild VR image that could not feel any movement.
Conclusions: VR images can reduce the equilibrium score of even in normal subjects. It is necessary to provide a standardized safety rating for each image with sufficient warnings of balance impairment.
PP1-154 - Relationship between cognitive function and balance in a community-dwelling population in Japan.
11. Gait, Posture, and Locomotion
Shinichi Goto
1
Akira Sasaki1, Ippei Takahashi2, Shigeyuki Nakaji2, Atsushi Matsubara1
1 Department of Otorhinolaryngology, Hirosaki University Graduate School of Medicine
2 Department of Social Medicine, Hirosaki University School of Medicine
Purpose: There has been not yet found treatment that cure dementia. For that, it is important to establish the evaluation index of cognitive decline before becoming dementia. The purpose of this study was to clarify the effective balance test indicating early cognitive decline by gender.
Methods: A total of 218 volunteers (60 years of age and over) who participated in the Iwaki promotion health poroject in 2015 were recruited. We performed three balance tests: one leg standing test, functional reach test and static posturography, and we used mini-mental state examination (MMSE) to investigate cognitive function.
Results: The MMSE scores were significantly lower in men than women. As a result of analysis of covariance, there was a statistically significant trend in only men that the more the MMSE score declined, the longer became the path length with both eyes opened and closed. In the result of multiple regression analysis, there was a significant negative association with MMSE score and path length with eyes opened or closed in men. There was no significant association with MMSE scores and balance tests in women.
Conclusions: The study suggests that static posturography might be a useful balance test to assess early cognitive decline in men.
PP1-155 - Spatiotemporal parameters and variability with changes in gait velocity in bilateral vestibulopathy
11. Gait, Posture, and Locomotion
Christopher McCrum1
Paul Willems1, Florence Lucieer2,
Raymond van de Berg2, Herman Kingma2, Kiros Karamanidis3, Kenneth Meijer1
1 NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University Medical Centre+, Department of Human Movement Science, Maastricht, The Netherlands
2 Division of Balance Disorders, Department of Otolaryngology, Head and Neck Surgery, Maastricht University Medical Centre+, Maastricht, The Netherlands
3 Sport and Exercise Science Research Centre, School of Applied Sciences, London South Bank University, London, UK
Purpose: The vestibular influence on gait appears to be suppressed with increased velocity. In this preliminary study, we aimed to assess spatiotemporal gait characteristics and their variability across different walking speeds in patients with bilateral vestibulopathy (BVP) and healthy controls.
Methods: 19 participants (Age: 55±13y) with BVP who could walk independently and 10 healthy control participants (Age: 25±3) participated. Experiments were conducted on the CAREN (combined motion capture, split-belt force plate-instrumented treadmill and virtual environment; Motekforce Link, Amsterdam) using a retroreflective marker on each hallux in combination with force plate data. Following familiarisation, participants completed two-minute walking bouts at seven different speeds (0.4m/s, 0.6m/s, 0.8m/s, 1.0m/s, 1.2m/s, 1.4m/s, 1.6m/s). Means and coefficients of variation (CV) of stride length and time, step width and double support time were calculated from 60 strides per speed. Two way ANOVAs with speed and participant group as factors were conducted.
Results: Walking speed effects were found for all parameters (P<0.0001). Group effects were found for the means of stride time and length (BVP led to faster, shorter strides; P<0.05) and for the CV of stride length, double support and step width (BVP more variable). Interactions were found for the means of all parameters (P<0.05), whereas the only interaction found for CV was step width (P<0.0001), where BVP led to greater increases in step width CV with increasing speed.
Conclusions: BVP led to increased gait variability compared to controls. It seems that vestibular sensory information may be especially important for regulating step width variability, in particular at faster walking speeds.
PP1-156 - Stabilogram of patients with otolithic vertigo
11. Gait, Posture, and Locomotion
Takaaki Kobayashi
1
Toru Seo1, Ko Shiraishi1, Katsumi Doi1
1 Kindai University Faculty of Medicine, Japan
Purpose: Due to the development of VEMP test, clinical concept of the otolithic vertigo (OV) has been established. Pathogenic linear moving sensation with up-to-down direction, anteroposterior direction, and right-and-left direction relate to the otolith disorders. To date, it has not been discussed in detail whether posture control is accompanied in patients with OV. To clarify the relationship between posture control and OV, we investigated the result of their stabilogram.
Methods: Thirty patients with OV were enrolled in this study. The tentative diagnostic criteria of OV was following as; 1) the complaint was of non-rotatory disequilibrium, 2) abnormal results were shown on cVEMP and/or oVEMP, 3) there were no abnormal results from routine examinations, 4) there were no cerebellar signs or intracranial lesions detected by brain MRI. For the control group, five subjects who have 1),2),4),but don’t have 3) were enrolled.The results of stabilography such as enveloped area (ENV area) and deviations of X, Y were evaluated, the obtained values were evaluated using deviation values to avoid influences of age and gender. The function of saccule and utricle were evaluated by cVEMP and oVEMP respectively.
Results: In the OV group, the ENV area tended to be larger as compared with the control group. In addition, among the Utricle disorder group, ENV area and maximum amplitude indicated larger than the other two groups.
Conclusions: Abnormal postural control which was associated with OV patients, and in particular the utricular organs had more influence on the postural control than saccular organs.
PP1-157 - The characteristics of balance sensory weight of sudden hearing loss with vertigo
11. Gait, Posture, and Locomotion
ma yuanxu
1
wang wei1, zheng yongzhe1, lin peng1, chen taisheng1, xu kaixu1, Li Shanshan1, wen chao1, liu qiang1
1 Tianjin First Center Hospital, Otorhinolaryngology Head and Neck Surgery, China
Purpose: To discuss the characteristics of balance sensory weight and evaluate the clinical significance of dynamic balance test for sudden hearing loss with vertigo.
Methods: Experimental group: 36 cases of sudden hearing loss (all patients were unilateral sudden deafness); Control group: 59 healthy volunteers. Both groups were accepted caloric test and dynamic balance test.
Results: The dynamic balance test detected the abnormal sensation weight under different conditions of SOT in experimental group. Balance score Median(Q25Q75) of experimental group was lower than control group in 6 conditions. SOT comprehensive score of control group80.24± 5.37, experimental group57.78±11.28; Median(Q25Q75) of somesthetic weight , visual weight, vestibule weight were abnormal distribution , SOT comprehensive score of experimental group was lower than control group. According to the SOT comprehensive score and the sense weight, divide the patients into three types. The peripheral injury of vestibule is mainly visual vestibule disorder and simple vestibule disorder. Compared the detection rate of caloric test and dynamic balance test in the experimental group, caloric test was positive 36 cases (100%), SOT was positive 33 cases 91.7%, both tests were positive 33 case 91.7%, both tests were negative 0 case, just caloric test was positive 3 cases 8.3%, just SOT was positive 0 cases 0.0%.
Conclusions: SOT is an important and effective method to evaluate the balance function of patients in sudden hearing loss with vertigo.
PP1-158 - Episodic ataxia type 2 characterized by recurrent dizziness/vertigo: a report of four cases
12. Genetics, Development, and Regeneration
Xia Ling
1
Xu Yang1
1 Department of Neurology, Aerospace Center Hospital, Peking University Aerospace School of Clinical Medicine, Beijing, China.
Purpose: To report the clinical features and gene mutations in four episodic ataxia type 2 (EA2) patients whose main presentation was recurrent dizziness/vertigo.
Methods: Clinical data of four EA2 patients (three familial EA2 cases and one sporadic case) with recurrent dizziness/vertigo were collected to assess nystagmus and eye movement. Gene mutations were identified by whole exome sequencing.
Results: The three patients in family 1 experienced disease onset before 8 years of age, mainly manifesting as episodic dizziness and muscle weakness of the lower limbs and the inability to walk. These symptoms lasted a few hours and then subsided. The proband also had gaze-evoked nystagmus during attacks. Videonystagmography demonstrated that the saccade velocity was low, smooth pursuit was type III, and gain was abnormal at 0.1 Hz, 0.2 Hz, and 0.4 Hz. The optokinetic nystagmus test showed that the left eye optokinetic nystagmus disappeared, and the right eye optokinetic nystagmus weakened. The head shaking test produced a left horizontal nystagmus. Gene analysis identified a novel c.1558+2T>G splice site mutation in the CACNA1A gene in the proband and his mother. The fourth patient was sporadic, with an onset age of 3 years. He mainly suffered from episodic vertigo, accompanied by severe anxiety and depression. He carried a CACNA1A mutation, c.4636C>T, which is a previously reported pathogenic mutation.
Conclusions: The onset of symptoms in these EA2 patients was early. The patients mainly presented recurrent dizziness/vertigo, with the absence of characteristic episodic ataxia. Detection of CACNA1A mutations facilitates the diagnosis of EA2.
PP1-159 - Genome-wide association study in downbeat nystagmus
12. Genetics, Development, and Regeneration
Michael Strupp
1
Sophia Wollenteit2, Ina Giegling3, Bettina Konte4, Annette M. Hartmann4, Stephan Maul4, Dan Rujescu3
1 University Hospital Munich, German Center for Vertigo and Balance Disorders, Germany; University Hospital Munich, Department of Neurology, Germany
2 University Hospital Munich, German Center for Vertigo and Balance Disorders, Germany
3 University Hospital Munich, German Center for Vertigo and Balance Disorders, Germany; Martin-Luther-University Halle-Wittenberg, Department of Psychiatry, Psychotherapy and Psychosomatics, Germany
4 Martin-Luther-University Halle-Wittenberg, Department of Psychiatry, Psychotherapy and Psychosomatics, Germany
Purpose: In order to identify genetic variants associated with downbeat nystagmus (DBN), which is mostly caused by a bilateral hypofunction of the cerebellar flocculus and whose etiology remains often unclear, we conducted a genome-wide association study (GWAS).
Methods: 106 patients (46 females) with DBN of unknown etiology and 2609 healthy controls of European ancestry were included. Association was assessed using app. 8 million single nucleotide polymorphisms after imputation in 7 batches.
Results: Two loci comprising three genes were identified to be genome-wide significant: fibroblast growth factor 14 (FGF14) on chromosome 13 and on chromosome 5 the dihydrofolate reductase (DHFR) and the mutS (Mutase S) homolog 3 (MSH3), a component of the post-replicative DNA mismatch repair system (MMR). DHFR and MSH3 have an overlapping area in their exons 1.
Conclusions: By using a GWAS approach to determine the etiology of downbeat nystagmus three genes were identified which are known to be associated with cerebellar impairment, a feature discussed in the context of DBN etiology. These findings provide canidate genes which could be involved in the underlying pathophysiology of downbeat nystagmus.
PP1-160 - Molecular genetic studies of Familial Menieres disease: a systematic review
12. Genetics, Development, and Regeneration
Qiuju Wang
1
Jing Zhang1, Hongyang Wang1, Jing Guan1, Dayong Wang1, Lidong Zhao1
1 Chinese PLA Institute of Otolaryngology, Chinese PLA General Hospital, Medical School of Chinese PLA
Purpose: Familial Meniere’s disease (FMD) ,which defined as at least one other relative (first or second degree) fulfills all the criteria of MD .FMD can offer a common genetic background for the subjects in studies and a growing number of FMD genetic studies have been reported with the rapid development of molecular genetic technology in recent decades, particular the application of next generation sequencing (NGS) technology. This systematic review summarized overall published articles with molecular genetic studies of FMD, which benefits to explore a more elaborated search strategy to identify novel causal genes and ultimately unveil the mysterious causes of MD.
Methods: We searched three electronic databases and reference lists up to August 2017. Three collaborators reviewed all the articles and disagreement was resolved through discussion.
Results: 13 studies met the eligibility criteria in this systematic review and more than 102 FMD pedigrees from six ethnics origins exhibited complex clinical and genetic heterogeneity of MD. A majority of FMD pedigrees exhibited autosomal dominant inheritance with incomplete penetrance and anticipation also observed in some enrolled researches. Linkage studies in FMD have found candidate loci at 5q14–15 and 12p12.3.By exome sequencing,DTNA,FAM136A, SEMA3D,DPT and PRKCB II genes had been identified.
Conclusions: Combination NGS followed by advanced Bioinformatics analysis on multi-generation families FMD and the latest diagnostic criteria of MD can bright a beam of new light to genetic basis studies of FMD ,which is also a quite reliable strategy to identify novel mutated genes and further unveil the underlying causes of MD.
PP1-161 - Regenerative medicine for vestibular disorders
12. Genetics, Development, and Regeneration
JUICHI ITO
1
HIDEAKI OGITA1, AKIKO TAURA1, KOJI NISHIMURA2, HIROE ONISHI2
1 Shiga Medical Center Research Institute, Japan
2 Department of Otolaryngology Head and Neck Surgery, Kyoto University, Japan
Purpose: It has become possible to restore the function for highly hearing-impaired patients using advanced artificial auditory instruments such as cochlear implants. However, treatment method for severely vestibular disordered patients has not been established.
Vestibular hair cells and vestibular ganglion cells are the main regions of peripheral vestibular damage. Both are related with age - related equilibrium disorders, as the number of those cells decrease with aging.
Once mammalian those cells are injured with aging or some other reasons, regeneration of those cells is considered difficult.
Methods: In recent years, regenerative medicine using stem cells such as embryonic stem cells (ES cells) and induced pluripotent stem cells (iPS cells) has developed. Clinical applications are gradually advanced in various fields such as ophthalmic field and cardiovascular field. In the field of ophthalmology retinal pigmented epithelium prepared from iPS cells was transplanted to patients of age-related macular degeneration and iPS-derived nerve cell transplantation is planned to transplant for patients of Parkinson’s disease and spinal cord injury. Realization of regenerative medicine for vestibular disordered patients is expected.
Results: We have tried to transplant stem cells into the inner ear of normal and peripheral vestibular damaged model animals. As donor stem cells we have used mouse or human iPS cells. We have confirmed whether transplanted stem cells can survive in the environment of vestibular organs. Then we have investigated the effectiveness of cell transplantation using animal models of vestibular damaged.
Conclusions: The present situation on vestibular regeneration medicine and the future prospect for regenerative medicine will be presented.
PP1-162 - Voltage-gated Ion Channels in the Developing Human Inner Ear
12. Genetics, Development, and Regeneration
Rikki K Quinn1
Hannah R Drury1, Melissa A Tadros1, Robert J Callister1, Alan M Brichta1,
Rebecca Lim
1
1 The University of Newcastle, Faculty of Health and Medicine, Australia
Purpose: Studies investigating inner ear development focus primarily on rodent models. The aim of this study was to determine the expression patterns of important potassium and calcium channels in the utricle, cristae, and cochlea of the human developing inner ear.
Methods: Inner ears from human foetus aged 9 to 17 weeks gestation were dissected to isolate vestibular (utricle and cristae) and cochlea (apex, middle, and base) regions. Tissue was homogenised and RNA isolated using QIAGEN miRNeasy Mini Kits. RNA was reverse transcribed into cDNA using Superscript III Reverse Transcriptase and qPCR run to assess ion channel expression (KCNQ4, CACNA1C) in the inner ear.
Results: Expression of potassium (KCNQ4), calcium (CACNA1C) channels were significantly higher in the middle region of the cochlea than other regions. KCNQ4 showed significantly lower expression in the cristae than utricle or cochlea regions, but did increase with gestational age in most regions of the inner ear. In contrast, there is a divergent pattern of CACNA1C expression with a decrease in vestibular organs, but increase in cochlea with gestational age.
Conclusions: Our results show that ion channel expression in developing human fetus varies with gestational age and across inner ear regions. The reason for these regional differences is unclear. Identifying key ion channels involved in functional development of HCs and their spatial expression may allow us to promote regenerative HC growth from pluripotent stem cells. This in turn, may lead to targeted treatments for deafness and balance disorders of the inner ear.
Exhibition and poster viewing (poster session 2)
PP2-1 - Auditory-Vestibular Integration at the Posterior Superior Temporal Gyrus and Posterior Insula Gyrus
13. Imaging of the Inner Ear & Vestibular System
Sun-Young Oh
1
Rainer Boegle2, Matthias Ertl3, Thomas Stephan3, Marianne Dieterich3
1 Department of Neurology, Chonbuk National University School of Medicine, Jeonju, Korea
2 Graduate School of Systemic Neuroscience, Ludwig-Maximilians University, Munich, Germany
3 Department of Neurology, Ludwig-Maximilians-University, Munich, Germany
Purpose: Multisensory convergence and sensorimotor integration are important aspects for the mediation of higher vestibular cognitive functions at the cortical level.Much less is known about the neural mechanism that mediates the integration of vestibular-otolith (linear acceleration/translation/gravity detection) and auditory processing. Vestibular-otolith and auditory afferents can be simultaneously activated using loud sound pressure stimulation, which are routinely used for testing cervical and ocular vestibular evoked myogenic potentials (VEMPs) in clinical testing. Due to the simultaneous activation of afferents there is always an auditory confound problem in fMRI studies of the neural topology of these systems. Here, we demonstrate that the auditory confounding problem can be overcome in a novel way that does not require the assumption of simple subtraction and additionally allows detection of non-linear changes in the response due to vestibular-otolith interference.
Methods: We used a parametric sound pressure stimulation design that takes each subject’s vestibular stimulation threshold into account and analysed for changes in BOLD-response below and above vestibular-otolith threshold.
Results: Results revealed that auditory and vestibular convergence are contained in overlapping regions of the caudal part of the superior temporal gyrus (STG) and the posterior insula. In addition, there are regions that were responsive only to suprathreshold stimulations, suggesting vestibular (otolith) signal processing in these areas.
Conclusions: Based on these parametric analyses, we suggest that the caudal part of the STG and posterior insula could be areas of vestibular contribution to auditory processing, i.e., higher vestibular cortices that provide multisensory integration that is important to tasks such as spatial localization of sound
PP2-2 - Imaging analysis of patients with Menieres disease treated with endolymphatic sac shunt surgery
13. Imaging of the Inner Ear & Vestibular System
Daogong Zhang
1
Yafeng Lv1, Yawei Li1, Honglu Shi2, Yuechen Han1, Zhaomin Fan1, Haibo Wang1
1 Department of Otorhinolaryngology-Head and Neck Surgery, Shandong Provincial Hospital affiliated to Shandong University, Jinan, China
2 Shandong Medical Imaging Research Institute Affiliated to Shandong University, Jinan, China
Purpose: To investigate the mechanism by which endolymphatic sac-mastoid shunt surgery is effective in treating Meniere’s disease.
Methods: Eleven patients with intractable Meniere’s disease underwent 3D-FLAIR MRI with a 3-Tesla unit 24 h after intratympanic administration of gadolinium before and six months after endolymphatic sac-mastoid shunt surgery. The enhanced perilymphatic space in the bilateral cochlea, vestibules and canals was visualized and compared with that in the endolymphatic space by scoring the scala tympani and scala vestibuli of the cochlear basal turn and by measuring the developing area of the vestibules quantitatively.
Results: Gadolinium was present in the perilymph of the inner ear in the cochlea, vestibules and canals of all 11 patients. Significant differences were observed in scala vestibuli scores between the affected and healthy sides (Z=3.426, P<0.05) and in the developing areas of the vestibules on the affected and healthy sides (5.76±2.99 mm2 vs. 8.89±2.52 mm2, t =2.65, P<0.05). The scala vestibuli scores before and after surgery did not differ on either the affected (Z=0.447, P>0.05) or healthy (Z=0.0, P>0.05) side. The developing area of the vestibule before and after surgery was also similar on the affected (t =0.74, P>0.05) and healthy (t =0.66, P>0.05) sides.
Conclusions: Hydrops was not significantly reduced by surgery. The mechanism by which endolymphatic sac-mastoid shunt surgery controls vertigo may be unrelate to improvements in endolymphatic hydrops.
PP2-3 - Multiplanar visualization of vestibular endolymphatic hydrops
13. Imaging of the Inner Ear & Vestibular System
Aram Keywan
1
Wilhelm Flatz2, Robert Guerkov3
1 Ear, Nose and Throat department & The German Centre for Vertigo and Balance disorders; University Hospital Munich (LMU); Germany
2 Department of Radiology; University Hospital Munich (LMU); Germany
3 Ear, Nose and Throat department; University Hospital Munich (LMU); Germany
Purpose: Recently developed magnetic resonance (MR) image acquisition techniques have enabled the visualization of endolymphatic hydrops (ELH). MR images are most commonly viewed in the axial plane; with studies attempting to visualize/quantify ELH in the sagittal and coronal planes being rather scarce. Therefore, our aim in this study was to provide a visual, colour-coded anatomical account of ELH in the three planes.
Methods: The inner ear region acquired with a 3D Real-IR sequence was extracted in four patients with varying degrees of ELH: 1) Normal inner ear fluid spaces, 2) Mild ELH, 3) Moderate ELH, 4) Severe ELH. For each patient, axial images were viewed alongside the sagittal and coronal images using a designated software. A 3D model constructed from histological image data of the inner ear was used as a visual reference.
Results: All ELH regions were identified and marked with different colour codes in the three planes. In the axial and coronal planes, mild dilatation of the sacculus is well recognized. In the sagittal plane, the shape of the utriculus is well recognized and facilitates the interpretation of axial images. With increasing severity of ELH, the utricular and saccular endolymph fluid spaces are converging and cannot be individually quantified in all given planes.
Conclusions: Multiplanar visualization of vestibular endolymphatic hydrops is highly informative and may serve as a better basis for the estimation and quantification of ELH than a uniplanar analysis
PP2-4 - New strategy for diagnosis of Menieres disease using three dimensional MRI
13. Imaging of the Inner Ear & Vestibular System
Taeko Ito
1
Hiroshi Inui2, Takashi Inoue3, Yuka Katsube2, Tsuyoshi Sakamoto4, Toshiaki Yamanaka1, Masato Kasahara3, Tadashi Kitahara1
1 Nara Medical University, Department of Otolaryngology -Head and Neck surgery-, Japan
2 Inui ENT clinic, Department of Otolaryngology, Japan
3 Nara Medical University, Institute for Clinical and Translational Science, Japan
4 Pixspace Ltd, Japan
Purpose: It has long been considered difficult to detect endolymphatic hydrops (EH) in patients with Meniere’s disease (MD) clinically using morphological examinations. In 2006, the Nagoya University group first succeeded in visualizing EH using MRI enhanced by intravenous administration of Gadolinium (Gd). The purpose of the present is to establish the criteria for diagnosis of MD using MRI.
Methods: Seventy patients with unilateral MD (uMD) were enrolled in the present. We also enrolled 47 healthy volunteers as controls. MRI measurements were performed 4 h after intravenous administration of a single dose of Gd contrast agent. The imaging was performed on a 3 tesla MRI unit using a 32-channel array head coil. The original MRI images were transferred to a workstation, and three-dimensional images were made. On this workstation, inner ears (cochlea, vestibule and semi-circular canals) were separated from brain and the volume of each structure was calculated. We also calculated the ratio of endolymphatic space size to total fluid space (ELS ratio). Comparing the ELS ratio of uMD with controls, we established the criteria for diagnosis of MD.
Results: The average of ELS ratio of uMD was 25.4% in cochlea, 37.0% in vestibule and 27.8% in semi-circular canals. On the other hand, the average of controls was 10.2% in cochlea, 17.7% in vestibule and 14.8% in semi-circular canals. Drawing the ROC curve with consideration of the relationship among all three parts, the AUC was 0.903 and AIC was 171.4.
Conclusions: The volumetric measurement of endolymphatic space size is useful for the diagnosis of MD.
PP2-5 - Progression of Hydrops in Meniere’s disease continues over time though the symptoms are relieved
13. Imaging of the Inner Ear & Vestibular System
Jungmin Ahn
1
Se Eun Son1, Yi-Kyung Kim2, Hyung jin Kim2, Won-Ho Chung1
1 Department of Otorhinolaryngology-Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
2 Department of Radiology, Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul, South Korea
Purpose: To evaluate the change of endolymphatic hydrops (EHs) in patients with unilateral MD, as a function of disease duration and clinical symptoms by intravenous Gd-enhanced inner ear MRI.
Methods: Total 26 patients with unilateral definite MD were enrolled in this study. Intravenous Gd-enhanced inner ear MRI was performed to visualize the endolymphatic hydrops of affected ear. Clinical features such as disease duration, pure tone audiometry (PTA), electrocochleography (ECoG), Caloric tests were assessed. The relationship between the hydrops ratio of cochlea and vestibule and disease duration was analyzed. Also, in 14 patients out of 26 participants, intravenous Gd MRI was repeatedly checked after the disappearance of vertigo spell for at least six months after medical treatment. In these patients, the sequential MRI in the same patients was compared to evaluate the change of hydrops ratio over at least 1-year duration and after the disappearance of vertigo for at least 6 months.
Results: The hydrops ratio of the patients was 0.38±0.19 in the cochlea and 0.61±0.25 in the vestibule. The mean disease duration was 34.4 months. The hydrops ratio in the cochlea and vestibule has increased over time. In addition, in 14 patients having sequential MRI, the hydrops ratio in cochlea and vestibule increased from 0.29 to 0.35, and from 0.65 to 0.73, respectively, despite the similar hearing thresholds.
Conclusions: The endolymphatic hydrops level has increased over time in the patients with MD despite the controlled vertigo spell. These indicated that the endolymphatic hydrops might be the irreversible and progressive phenomenon in MD.
PP2-6 - The Feasibility of MRI in the Differential Diagnosis of a patient with Acute Audiovestibular Loss
13. Imaging of the Inner Ear & Vestibular System
Jong Dae Lee
1
Seung Jae Lee1, Se A Lee1, Ji Ye Lee2
1 Department of Otorhinolaryngology-Head and Neck Surgery, Soonchunhyang University College of Medicine, Korea
2 Department of Radiology, Soonchunhyang University College of Medicine, Korea
Purpose: Acute audiovestibular loss is characterized by acute onset of prolonged vertigo and hearing loss. Many neurologic conditions should be considered in the differential diagnosis of audiovestibular loss. Some authors suggest that acute audiovestibular loss is more often caused by vascular factors rather than viral causes. The purpose of this study is aimed to identify the feasibility of MRI in the differential diagnosis of patients with acute audiovestibular loss.
Methods: We retrospectively enrolled 31 patients who fulfilled the criteria for sudden hearing loss at symptom onset and showed spontaneous nystagmus from March 2007 to December 2017. Patients were excluded if the examination indicated Meniere’s disease or chronic otitis media. Temporal MRI including Diffusion-Weighted Imaging (DWI) and Fast Imaging Employing Steady-state Acquisition (FIESTA) were taken in all patients
Results: Fifteen patients showed increased signal of labyrinth on FLuid-Attenuated Inversion Recovery (FLAIR) image and 9 patients showed negative findings on MRI. Two patients showed an infarction of AICA territory in DWI MRI and 3 patients showed vestibular schwannoma in the internal auditory canal. There was no significant relevance between hearing recovery after treatment and the FLAIR image
Conclusions: Although MRI examination is mandatory to distinguish central vertigo in acute audiovestibular loss, the presence of AICA infarction was rarely seen and few patients showed central, non-stroke cases such as vestibular schwannoma
PP2-7 - Usefulness of intravital multi-photon microscopy in visualizing study of the scala media
13. Imaging of the Inner Ear & Vestibular System
Young Joon Seo
1
Bo Yeon Lee1, Tae Hoon Kong1, Yoon Ah Park1
1 Yonsei University Wonju College of Medicine
Purpose: Currently, no vestibular or auditory diagnostic test is available for endolymphatic hydrops or dilation of the scala media. Clinical diagnosis for endolymphatic hydrops is based on doctor’s observation and patient’s medical history, symptomatic and symptomatic pattern. By using near-infrared lasers for multi-photon excitation, intravital multi-photon microscopy (MPM) can detect endogenous fluorescence and second harmonic generation of tissues. In this study, we used intravital MPM to visualise various cochlear microstructures without any staining and non-invasively analyse the volume changes of the scala media without removing the overlying cochlear bone.
Methods:
Results: The intravital MPM images revealed various tissue types, ranging from thin membranes to dense bone, as well as the spiral ganglion beneath the cochlear bone. The two-dimensional cross-sectional and serial z-stack intravital MPM images also revealed the spatial dilation of the scala media in the temporal bone of pendrin-deficient mice.
Conclusions: These findings suggest that intravital MPM might serve as a new method for obtaining microanatomical information regarding the cochlea, similar to standard histopathological analyses in the animal study for the cochlea. Given the capability of intravital MPM for detecting an increase in the volume of the scala media in pendrin-deficient mice, it might be a promising new tool for assessing the pathophysiology of hearing loss in the future.
PP2-8 - Antigen in the Endolymphatic Duct results in Chronic Hydrops and an Enlarged Endolymphatic Duct
14. Meniere’s Disease and Related Disorders
Daniel Brown
1
Ljiliana Sokolic1, Albert Fung1, Christopher Pastras1
1 Sydney Medical School, The University of Sydney, NSW, Australia
Purpose: Antigen within the endolymphatic space is said to be transported to the endolymphatic sac. It has been suggested that permanent damage of the sac via excessive immune activity can result in chronic endolymphatic hydrops. However, the injection of antigen, such as Lipopolysaccharide (LPS), into inner ear perilymph results in a temporary endolymphatic hydrops that lasts only 2 to 3 weeks. Here, we investigated changes induced by antigen injected directly into the endolymphatic space.
Methods: Various concentrations of LPS in 1ml of artificial endolymph were injected into scala media of anaesthetized guinea pigs via a glass micropipette, with subsequent recovery for 1 to 6 weeks. Artificial endolymph injections and contralateral ears served as controls. After the recovery period, cochlear and vestibular function was measured, and inner ears were imaged using light-sheet fluorescence microscopy. The relative volume of scala media and the endolymphatic duct was quantified.
Results: Functional and morphological changes varied with LPS concentration, ranging from severe fibrosis and hearing loss (0.1%LPS), to no fibrosis with moderate endolymphatic hydrops with only mild hearing loss (0.005% LPS). Interestingly fibrosis and hydrops in scala media coincided with an enlarged, patent endolymphatic duct.
Conclusions: Injections of 0.001% LPS produced hydrops lasting at least 6 weeks, with less than 20 dB hearing loss. This may offer a more reliable method of inducing chronic endolymphatic hydrops in guinea pigs for Meniere’s disease research. Moreover, our results highlight that immunological damage of the endolymphatic sac may not result in blockage of the duct.
PP2-9 - Bilateral Meniere’s disease or autoimmune inner ear disease presenting to the Emergency Department
14. Meniere’s Disease and Related Disorders
KUMIKO YUKAWA ORIMOTO
1
Michael Dobson2, Maria Vartanyan2, Claire Iseli3, Stephen O’Leary1
1 The University of Melbourne, The Royal Victorian Eye and Ear Hospital
2 The Royal Victorian Eye and Ear Hospital
3 The University of Melbourne, The Royal Victorian Eye and Ear Hospital, The Royal Melbourne Hospital
Purpose: To describe the clinical presentations of patients with bilateral Meniere’s Disease (MD) or Autoimmune Inner Ear Disease (AIED) to our Emergency Department (ED) of the Royal Victorian Eye and Ear Hospital. This ED provides a Statewide service for ear-related disease.
Methods: Search strategy: Patients presenting to ED between Jan 2015-Dec 2017, with a diagnostic code of MD (134 patients), who were followed up with at least one audiogram, and met the recent Barany Society criteria for definite MD (in 2015). Thirty nine met these criteria, and of these eight had bilateral disease.
Results: The period of time between diagnosis of unilateral disease, and emergence of bilateral MD was 3-16 years. In six cases, the hearing loss was sequential commencing as a low-to-middle frequency hearing loss in one ear and then the other. Two cases exhibited bilateral simultaneous hearing fluctuation. Most patients exhibited a high frequency hearing loss. It was the better-hearing ear that fluctuated. Three of these patients were seropositive for c-ANCA or the antinuclear antibody. Other patients had associated autoimmune conditions, including inflammatory arthritis and diabetis mellitus. One patient showed inflammation of the cervical spine, with rapidly progressive bilateral SNHL.
Three people required cochlear implantation, including the rapidly progressive bilateral hearing loss patient. Fluctuation of the better-hearing ear caused considererable disability for the patient.
Conclusions: Approximately 20 % cases of Meniere’s presented with bilateral disease. Autoimmune disease was frequently associated, and in one case the condition was associated with serious neurological disease. Progression to bilateral MD can occur many years after initial presentation.
PP2-10 - Cervical and Ocular Vestibular-evoked Myogenic Potentials in Patients with Menieres Disease
14. Meniere’s Disease and Related Disorders
Qing Zhang
1
Xiaorong Niu2, Peng Han2, Yuzhong Zhang1, Zichen Chen1, Juan Hu1, Maoli Duan1, Min Xu1
1 Department of Otorhinolaryngology Head and Neck Surgery, Second Affiliated Hospital, Xi’an Jiaotong University
2 Department of Otorhinolaryngology Head and Neck Surgery, First Affiliated Hospital, Xi’an Jiaotong University
Purpose: To observe the features of air-conducted sound elicited ocular vestibular-evoked myogenic potential(ACS-oVEMP) and cervical vestibular-evoked myogenic potential(ACS-cVEMP) in patients with Meniere’s disease (MD).
Methods: Fifty six patients with MD and 50 normal subjects (100 ears) were recruited for conventional cVEMP and oVEMP examinations. Grade of vestibular function was also collected for patients with MD. The relationship between VEMPs abnormity, grades of vestibular function and clinical stages of MD were analyzed.
Results: The abnormal rates of cVEMP and oVEMP in MD patients were 57.1% (32/56) and 64.3% (36/56), significantly higher than that in normal subjects respectively (X2=22.286P=0.000X2=15.217P=0.000). The abnormal rates of cVEMP and oVEMP in MD patients of stage to stage were 20.0% (1/5) and 40.0% (2/5), 50.0% (9/18) and 50.0% (9/18), 59.3% (16/27) and 70.4% (19/27), 100.0% (6/6) and 100.0% (6/6). There was a significant difference in cVEMP abnormity between four stages of MD patients (P=0.046). Significant correlation was found between clinical stages and the grades of vestibular dysfunction (rs=0.417P=0.001).
Conclusions: Dysfunction of vestibular otolithic organs and their input pathways in patients with MD can be detected by cVEMP and oVEMP tests. The abnormal rates of VEMP showed an gradually increasing trend with the development of MD stages. And the extent of vestibular lesions can be detected by cVEMP and oVEMP tests, which may provide a reference for clinical staging of MD.
PP2-11 - Clinical application of glycerol test with endolymphatic sac decompression in Meniere ‘s disease
14. Meniere’s Disease and Related Disorders
Zhan-guo Jin
1
Ping He1, Shun Dong1, Yuan-jun Li1, Xian-rong Xu1, Jian-chang Wang1
1 General Hospital of Air Force, Aerospace Balance Medical Center, Beijing, China
Purpose: To study the clinical value of glycerin test in the operation of inner ear lymphatic sac decompression in Meniere’s disease.
Methods: 82 patients with stage and Meniere’s disease with poor conservative treatment and definite diagnosis were given preoperative glycerol test and DARS score was recorded. After 2 years of follow-up, the DARS score was applied again. The correlation between glycerin test results and postoperative efficacy was analyzed.
Results: In 82 cases with Meniere’s disease, the positive result of hearing test in glycerin test was 57.32% of the total, 17 cases of positive hearing loss type was 20.73% and 18 cases of glycerin test negative rate was 21.95%. The DARS scores of 82 patients before and after surgery were 31.48 ± 7.05 and 8.44 ± 8.17respectively (P <0.01). The lowest preoperative DARS score was 7 and the highest was 36. The lowest DARS score was 0 and the highest was 29 at 2 years after operation. The DARS score of 8 patients was ≥18 and the operative efficiency was 78.92%. Among them, the positive rate of DARS in patients with positive glycerol test was (6.56±1.28) and negative in patients with glycerin test (10.47±3.09), there was a significant difference (P <0.05).
Conclusions: This studies have shown that the glycerol test for patients of Meniere’s disease with endolymphatic sac decompression has instructive significance. The positive result of the Glycerol test in the patients of Meniere’s disease with endolymphatic sac decompression was efficacy than the negative effect.
PP2-12 - Clinical features of symptom and audiovestibular test for Menieres disease and vestibular migraine
14. Meniere’s Disease and Related Disorders
Su-Lin Zhang
1
Bo Liu1, Yangming Leng1, Renhong Zhou1, Jingjing Liu1, Wei-Jia Kong1
1 Huazhong University of Science and Technology, Tongji Medical College, Union Hospital, Department of Otorhinolaryngology, P.R.China
Purpose: The diagnosis of Menière’s disease (MD) and vestibular migraine (VM) is principally based on clinical symptoms. Currently, no specific diagnostic tests and biological markers are available. Comorbidity is common between MD and VM, and their symptoms overlap, which renders the differential diagnosis difficult. Due to the similarities between MD and VM in the clinical symptoms and diagnostic criteria, and differences in their management, our research effort was mainly directed at their differentiation.
Methods: We examined the clinical features of MD, VM and MDVM in terms of demographics, symptoms and findings of neurotologic tests, audiometry and vestibular laboratory assessment.
Results: We investigated 252 patients with only VM, 168 with only MD, and 62 with MDVM. Clinical features that differentiated VM from MD were found in all groups. MD tended to have an advanced age of onset, more fluctuating or low tone hearing loss, progressive hearing loss, tinnitus, ear fullness, abnormal caloric asymmetry, abnormal vestibular evoked myogenic potential and endolymphatic hydrops (ELH on ECOG, -SP/AP amplitude ratio). On the other hand, VM tended to have family history of vertigo/dizziness, involved females more, and had higher attack frequency. Moreover, VM patients had more headaches, photophobia, phonophobia and visual aura, high tone hearing loss, abnormal nystagmus, and abnormal findings of vestibular autorotation test.
Conclusions: In conclusion, this study confirmed a considerable overlap of clinical symptoms among MD, VM and MDVM. Integrating clinical symptoms, the findings audiovestibular tests and follow-up can help differentiate the two conditions and find the comorbidity.
PP2-13 - Delayed contrast 3-dimensional MRI and regional hydrops in Meniere’s disease and variants.
14. Meniere’s Disease and Related Disorders
Gail Ishiyama
1
Ali Sepahdari2, Stellios Karnezis2, Akira Ishiyama3
1 UCLA School of Medicine, Dpmt of Neurology, USA
2 UCLA School of Medicine, Dpmt of Radiology, USA
3 UCLA School of Medicine, Dpmt of Head and Neck Surgery, USA
Purpose: To use high resolution MRI to evaluate endolymphatic hydrops in patients with Meniere’s disease (MD) and related entities.
Methods: MRI sequences with 3T scanner using high resolution 4 hour-delayed intravenous-enhanced 3D FLAIR including cisternographic T2 and delayed iv-enhanced 3D fluid-attenuation inversion recovery (DIVE-3D-FLAIR). Clinical history, audiovestibular testing, and evaluation by neurotologist. All sequential MRI imaging using hydrops protocol were evaluated during a 9 month period.
Results: There were 15 patients with MD with ipsilateral isolated saccular hydrops; 18 patients with MD with ipsilateral hydrops isolated to the saccule and cochlear duct and 15 patients with MD with hydrops in the saccule, cochlear duct, and utricle. Patients with isolated saccular hydrops had full MD with vertigo, aural fullness and ipsilateral hearing loss. In one case, serial MRI demonstrated isolated saccular hydrops progressing to cochleo-saccular hydrops as symptoms progressed. Six patients had isolated cochlear hydrops. 5 out of 6 of the isolated cochlear hydrops presented with fluctating hearing loss without associated vertigo spells, while one had full MD with vertigo spells.
Conclusions: There was a significant predominance of saccular endolymphatic hydrops with only one patient out of 48 MD patients without hydrops of the saccule. These findings are consistent with endolympahtic hydrops initiating from the saccule, then progressing to involve the cochlea and then utricle. There were 5 patients with isolated cochlear hydrops; it is unknown whether these patients will later go on to develop MD. High resolution MRI is useful to delineate the natural history of MD and other variants such as cochlear hydrops.
PP2-14 - Delayed effect and gain restoration after intratympanic gentamicin for Menieres Disease
14. Meniere’s Disease and Related Disorders
Eduardo Martin Sanz
1
Joaquin Yanes1, Jonathan Esteban1, Nicolas Perez Fernandez2
1 Universidad Europea de Madrid, University Hospital of Getafe, Madrid , Spain
2 Universidad de Navarra, Clinica Universidad de Navarra, Madrid, Spain
Purpose: To determine the clinical value of the video Head Impulse Test for monitoring the effect of intratympanic gentamicin in MD patients.
Methods: Twenty definite MD patients treated with intratympanic gentamicin were enrolled in this prospective study.Patients underwent a complete neuro-otologic examination, audiometry, caloric testing and a vHIT before beginning this protocol.Patients returned for weekly follow-up examination during the course of the treatment protocol. Subsequently were monitored 1 month after the completion of the therapy and were then seen at intervals of 3 months. Every patient was monitored for at least one year.
Results: Complete vertigo control (class A) was achieved in 14 patients at the 12-month follow-up. A significant reduction in the hVOR gain values was observed at the three weeks follow up after the instillation, with a maximum gain reduction at the one month evaluation after the gentamicin injection. Once this reduction was achieved, no additional was detected in subsequent testing.The ROC analysis showed that a hVOR gain diminution over 33% in the 1 month follow-up, results in a higher vertigo free period. In the mid-term, 10 patients had a significant partial recovery of the hVOR gain . Six out those 10 patients suffered vertigo recurrence, which paralleled the recovery of the hVOR gain.
Conclusions: Our results suggest that a monthly interval between injections, is a sufficiently safe period to wait until a reduction of the hVOR gain appears. Our findings are consistent with a mild relationship between gain restoration and vertigo recurrence.
PP2-15 - Detecting endolymphatic hydrops with posterior tympanic medial wall Gd-DTPA delivery and 8 min-MRI
14. Meniere’s Disease and Related Disorders
Jing Zou
1
Zhen Wang2, Yukun Chen2, Guoping Zhang1, Jianping Lu2, Hongliang Zheng1
1 Second Military Medical University/Changhai Hospital, Department of Otolaryngology-Head and Neck Surgery, China
2 Second Military Medical University/Changhai Hospital, Department of Radiology, China
Purpose: To optimize targeted posterior tympanic medial wall delivery of gadolinium chelate and MRI sequence for detection of endolymphatic hydrops (EH) in patients with peripheral vertigo.
Methods: 13 patients with periphery vertigo were enrolled in the study. 0.1-0.2 ml diluted (10,20, and 40-fold) gadolinium-diethylenetriamine pentaacetic acid (Gd-DTPA) were delivered onto the posterior tympanic medial wall using a soft-tipped needle. Heavily T2-weighted 3-dimensional fluid-attenuated inversion recovery (hT2W-3D-FLAIR) MRI with imaging time of either 8min 35sec or 15min 11sec was performed 8h or 24 h after administration using a 3T machine in combination with 20-channel Tim 4G head/neck coil.
Results: High signal to noise ratio MRI was generated in patients receiving delivery of 0.15-0.2ml of 10-fold diluted Gd-DTPA. At 8h after delivery, significant uptake was detected in the perilymhatic compartments of hook region and basal turn of cochlea and vestibule. At 24 h, Gd-DTPA distributed homogenously in the inner ear. Obvious individual variance existed in the uptake when 0.1 ml of 40-fold diluted Gd-DTPA was delivered. Stable inner ear uptake and high quality images demonstrating EH were gained in patients receiving 0.1ml of 20-fold diluted Gd-DTPA. There was insignificant difference in the image quality associated with different canning time. EH were detected in 6 cochleae and 11 vestibule. Cochlear EH was detected in definite Meniere’s disease patients.
Conclusions: Targeted posterior tympanic medial wall delivery of 0.1ml of 20-fold diluted Gd-DTPA in combination with 8min 35sec hT2W-3D-FLAIR MRI is clinically practical to detect EH. The study was supported by National Natural Science Foundation of China (contract 81771006.
PP2-16 - Diagnostic Diversity of Acute Vestibular Syndrome with Negative Video Head Impulse Test
14. Meniere’s Disease and Related Disorders
Min-Beom Kim
1
Jeesun Choi2, Jeong Yup Lee1
1 Department of Otolaryngology-Head and Neck Surgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
2 Soree Ear Clinic, Seoul, Korea
Purpose: To analyze the clinical characteristics of patients with acute vestibular syndrome (AVS) who showed negative video head impulse test (vHIT)
Methods: During 16 months, 155 of AVS were identified due to presence of spontaneous nystagmus and postural imbalance. Of these 155, 30(19.4%) were finally enrolled in this study due to both of the negative horizontal vHIT. Data on demographics (age, gender), results of vestibular function tests [video-nystagmography, horizontal vHIT, caloric test, and cervical vestibular evoked myogenic potential (cVEMP)] were analyzed. All cases were checked brain MRI including diffusion scan to evaluate central lesion.
Results: All 30 patients consisted of 17 cases of Meniere’s disease (MD), 7 of sudden sensorineural hearing loss (SSNHL) with vertigo, and only 3 cases (3/30, 10%) were finally diagnosed as acute vascular stroke. In MD, 5 patients showed negative vHIT even in unilateral canal paresis on caloric test. Except for hearing loss in the lesion side, the direction of nystagmus or cVEMP asymmetry were inconsistent to clarify the diagnosis. All 7 patients with SSNHL with vertigo did not have caloric canal paresis, but 6 patients showed amplitude of cVEMP was significantly smaller on the lesion side.
Conclusions: In patients with AVS, even in negative vHIT, peripheral vestibulopathy were still more common compared with stroke. Of these patients, it is mandatory to confirm hearing because of a high possibility of MD or SSNHL. In particular, negative vHIT in SSNHL with vertigo might be affected by involvement of inferior vestibular nerve or saccule.
PP2-17 - Diagnostic Value of the Multifrequency Tympanometry in the Patients with Menieres Disease
14. Meniere’s Disease and Related Disorders
Takamasa Yoshida
1
Kazuhiko Kubo2, Takashi Nakagawa2
1 Department of Otorhinolaryngology and Neurotology, Chidoribashi General Hospital, Fukuoka, JAPAN
2 Department of Otorhinolaryngology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, JAPAN
Purpose: Meniere’s disease (MD) is characterized by an idiopathic endolymph hydrops which reflects an increase in the pressure of inner ear. Multifreqency tympanometry (MFT) can evaluate the change in the pressure of inner ear. The aim of this study was to compare the efficacy of the pressure of inner ear in the patients with MD in order to measure G width (the width of bimodal peaks for the waveform obtained in measuring a conductance at 2000Hz) using MFT.
Methods: We have recruited 80 healthy control subjects and 51 patients who were referred to our department and were diagnosed as MD. MFT measured G width at a resonance frequency of 2000Hz in both ears of all subjects. This word was approved by an ethics committee at Chidoribashi General Hospital.
Results: G width in the affected ears with MD was significantly more elevated than that in the healthy ears in the control group. The cutoff value was set at 200daPa with a sensitivity of 35.1% and a specificity of 95.6%. On the other hand, There was no significant difference between resonance frequency of ears in the control group and ears with MD. Both ears in the MD group had a wider G width than that in the control group.
Conclusions: MFT is a noninvasive and easy device. These results suggest that MFT may be a useful tool to find out the elevated pressure of inner ear in the patients with MD.
PP2-18 - Discrepancies between vHIT and caloric tests in congenital and acquired endolymphatic hydrops
14. Meniere’s Disease and Related Disorders
Ji Hyung Kim
1
Jinsei Jung1, Sung Huhn Kim1, Michelle J. Suh1
1 Department of Otorhinolaryngology, Yonsei University College of Medicine, Seoul, Republic of Korea
Purpose: We investigated the video head impulse test (vHIT) and caloric test in enlarged vestibular aqueduct (EVA) patients and compared the findings with Ménière’s disease (MD) and acute vestibular neuritis results to clarify vestibular dysfunction characteristics in enlarged vestibular aqueduct patients and suggest the cause of discrepancy between the video head impulse and caloric tests in endolymphatic hydrops.
Methods: Ten enlarged vestibular aqueduct patients with genotypically proven bi-allelic SLC26A4 mutations were enrolled. The results of video head impulse and caloric tests were analyzed and compared with those of MD (n = 76) and acute vestibular neuritis (n = 19).
Results: In EVA patients, 40% showed unilateral caloric weakness and 30% had recurrent vertigo spells. All the patients with recurrent vertigo had caloric weakness. However, only 25% of patients with abnormal caloric test results showed abnormal vHIT results. The discrepancy between the caloric test and vHIT results was also found in patients with MD, but not in patients with acute vestibular neuritis (abnormal vHIT results in 47.3% and 94.7% of patients with unilateral caloric weakness, respectively).
Conclusions: Unilateral vestibular dysfunction was identified in 40% of EVA patients by caloric test, and caloric test results were not correlated with vHIT results, of which the finding was also similar in MD patients. It is tempting to speculate that endolymphatic hydrops, a common pathologic feature of EVA and MD, could cause the discrepancy, and vestibulopathy in endolymphatic hydrops might be restricted in the low-frequency range.
PP2-19 - Discrepancy between results of vHIT and those of caloric test in the cases with Menieres disease
14. Meniere’s Disease and Related Disorders
Toru Seo
1
Ko Shiraishi1, Takaaki Kobayashi1, Katsumi Doi1
1 Department of Otolaryngology, Kindai University, Japan
Purpose: It is well known that video head impulse test (vHIT) is a simple and reliable examination for vestibular function. The results are identical with those of the caloric test for cases with vestibular neuritis and acoustic tumor. On the contrary, the results of two tests diverge for the cases with Meniere’s disease. The aim of this study was to clarify the cause of the discrepancy.
Methods: Subjects were 22 cases of unilateral Meniere’s disease who showed unilateral dysfunction on the caloric test. We studied factors which affect the results of vHIT using logistic regression analysis.
Results: There was no association with respect to age, duration of disease, stage, frequency of vertigo or hearing level (p> 0.05). On the contrary, the results of vHIT associated with those of the Futaki’s furosemide test (p = 0.03).
Conclusions: The cause of the discrepancy had been controversial. One presumed cause was the difference of type of impaired hair cells. Type 2 cells which relates to caloric response are more susceptible to damage than type I cells which relates to response of vHIT in Ménière’s disease. Numbers of type 2 cells decrease with age, but the discrepancy is not related to age, so the theory is denied. Another presumed cause is changes of the lymph flow due to the hydrops. Since the Futaki’s furosemide test inspect having endolymphatic hydrops in the lateral semicircular canal, we sustain that enlarged endolymphatic space should cause the discrepancy between the results of vHIT and those of caloric test in Meniere’s disease.
PP2-20 - Dissociated vestibular tests result in patients with Menieres is not due to central dysfunction
14. Meniere’s Disease and Related Disorders
Nicolas Perez
1
Paloma Eza2, Raquel Manrique1, Maria de la Concepcion Fariñas3
1 University of Navarra
2 Hospital Sierrallana. Cantabria.
3 Hospital Universitario Marques de Valdecilla; IDIVAL. Cantabria
Purpose: In patients with Méniere’s disease the most frequent finding in vestibular testing is a discrepancy of results such that the caloric test is usually abnormal while the video-head impulse test is normal. The hypothesis to test is that if an abnormal velocity storage function is the basis for a discrepant result, then the time constant of the nystagmic response during rotatory chair testing should also be found abnormal (lower) and phase advance should be an expected finding.
Methods: A complete vestibular evaluation that included the caloric and video head-impulse test was performed to 50 patients diagnosed of unilateral definite Ménière’s disease and classified according to results in both tests. All then and 12 normal subjects, were also evaluated with the rotatory chair test. The time constant of the nystagmic response and the results in the test (gain and phase shift) were compared in the different groups and multivariate analysis was performed to analyze differences adjusted by age.
Results: The mean time constant and phase lead were only different to results in normal subjects when both the caloric and vHIT were abnormal. None of these results were different to those in normal subjects in patients with both tests normal neither in those in whom the results were discrepant.
Conclusions: In patients with unilateral Ménière’s disease, discrepant results in the vHIT and caloric test do not indicate an abnormal central vestibular processing of the information coming from the periphery when stimulated with hot or cold water.
PP2-21 - Eye Movement Response Patterns during vHIT in Menieres Disease or Migraine Related Vertigo
14. Meniere’s Disease and Related Disorders
Leonardo Manzari
1
Ann M. Burgess2, Julia Dlugaiczyk3, Ian S. Curthoys2
1 MSA ENT ACADEMY CENTER, Cassino (FR), Italy
2 Vestibular Research Laboratory, University of Sydney, NSW, Australia
3 Department of Otorhinolaryngology, Saarland University Medical Center, Homburg, Germany
Purpose: To compare the eye velocity response profiles of healthy subjects on vHIT to the response profiles of patients with early Meniere’s Disease or Migraine Related Vertigo.
Methods: Patients with stage 3 Definite Meniere’s Disease (MD) were enrolled and patients diagnosed as Migraine Related Vertigo (MRV). Healthy subjects in the same age range were tested as controls. MD patients had to be less than two years into MD. The ICS Impulse system measured the eye movement response to head impulses by vHIT using the HIMP paradigm: the subject or patient was instructed to maintain fixation on an earth-fixed target during small, abrupt, passive, unpredictable horizontal head turns in the plane of the horizontal canal.
Results: There are systematic differences between healthy subjects and both groups of patients in the eye velocity response. In healthy subjects the eye velocity closely matches head velocity at all parts of the head impulse and the area VOR gain is around 1.0, however typically MD and MRV patients show an early large eye acceleration, resulting in an eye velocity time series which looks saccadic. Not surprisingly, not all MD and MRV patients showed this “early onset” eye movement pattern.
Conclusions: We suggest that this early enhanced eye velocity in vHIT is due to hydrops. Fluid dynamic modelling of the effect of hydrops on the semicircular canal response during the head impulse (Grieser et al 2014) predicted the enhanced eye velocity we found.
PP2-22 - Fn14 and NF-B underlying inflammation in peripheral blood mononuclear cells in Meniere disease
14. Meniere’s Disease and Related Disorders
Lidia Frejo Navarro
1
Teresa Requena1, Satoshi Okawa2, Alvaro Gallego-Martinez1, Manuel Martinez-Bueno3, Ismael Aran4, Angel Batuecas-Caletrio5, Jesus Benitez6, Juan Manuel Espinosa-Sanchez7, Jesus Fraile8, Ana Maria Garcia-Arumi9, Rocio Gonzalez-Aguado10, Pedro Marques11, Eduardo Martin-Sanz12, Nicolas Perez13, Paz Perez14, Herminio Perez-Garrigues15, Sofia Santos-Perez16, Andres Soto-Varela16, Maria Cruz Tapia17, Gabriel Trinidad18, Antonio del Sol2, Marta Eugenia Alarcon-Riquelme19, Jose Antonio Lopez-Escamez7
1 Otology & Neurotology Group CTS495, Department of Genomic Medicine - Centre for Genomics and Oncological Research – Pfizer/Universidad de Granada/ Junta de Andalucía (GENYO), Granada, SPAIN
2 Computational Biology Group, Luxembourg Centre for Systems Biomedicine (LCSB), Universite du Luxembourg, Belvaux, LUXEMBOURG
3 Group of Genetics of Complex Diseases, Department of Genomic Medicine - Centre for Genomics and Oncological Research – Pfizer/Universidad de Granada/ Junta de Andalucía (GENYO), Granada, SPAIN
4 Department of Otolaryngology, Complexo Hospitalario de Pontevedra, Pontevedra, SPAIN
5 Department of Otolaryngology, Hospital Universitario Salamanca, Salamanca, SPAIN
6 Department of Otolaryngology, Hospital Universitario de Gran Canaria Dr Negrin, Las Palmas de Gran Canaria, Las Palmas, SPAIN
7 Department of Otolaryngology, Instituto de Investigación Biosanitaria ibs.GRANADA, Hospital Universitario Virgen de las Nieves, Granada, SPAIN
8 Department of Otolaryngology, Hospital Miguel Servet, Zaragoza, SPAIN
9 Department of Otorhinolaryngology, Hospital Universitario Vall d’Hebron, Barcelona, SPAIN
10 Department of Otorhinolaryngology, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, SPAIN
11 Department of Otorhinolaryngology, Centro Hospitalar de S.João, EPE, University of Porto Medical School, Porto, PORTUGAL
12 Department of Otolaryngology, Hospital Universitario de Getafe, Getafe, Madrid, SPAIN
13 Department of Otolaryngology, Clínica Universidad de Navarra, Pamplona, Spain
14 Department of Otorhinolaryngology, Hospital de Cabueñes, Gijón, Asturias, Spain
15 Department of Otorhinolaryngology, Hospital La Fe, Valencia, SPAIN
16 Division of Otoneurology, Department of Otorhinolaryngology, Complexo Hospitalario Universitario, Santiago de Compostela, SPAIN
17 Department of Otorhinolaryngology, Instituto Antolí Candela, Madrid, Spain
18 Division of Otoneurology, Department of Otorhinolaryngology, Complejo Hospitalario Badajoz, Badajoz, SPAIN
19 Unit of Chronic Inflammatory Diseases, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, SWEDEN
Purpose: The aim of this study was to identify susceptibility loci using the Immunochip genotyping array to define a subset of patients with MD which may have an autoimmune dysfunction.
Methods: We conducted a case-control study in two phases using an immune genotyping array in a total of 420 patients with bilateral MD and 1630 controls. We also performed a gene expression assay in homozygous genotype-selected peripheral blood mononuclear cells (PBMCs). Lymphoblastoid cell lines (LCL) were generated from the selected genotypes and qPCR, Western blot and confocal image analysis were performed to validate the expression array results. A phosphorylation assay was carried out to measure the amount of total and phosphorilated NFκB.
Results: We have identified the first locus, at 6p21.33, suggesting an association with bilateral MD (meta-analysis leading signal rs4947296, OR= 2.089 (1.661-2.627); P= 1.39×10-09). Gene expression profiles of homozygous genotype-selected peripheral blood mononuclear cells (PBMCs) demonstrated that this region is a trans-expression quantitative trait locus (eQTL) in PBMCs. Signalling analysis predicted several TNF-related pathways, being the TWEAK/Fn14 pathway the top candidate (P= 2.42×10-11).
Conclusions: These findings suggest that the carriers of the risk genotype may develop an NF-κB-mediated inflammatory response in PBMCs in MD.
PP2-23 - Incidence of progression Into Mnires Disease from idiopathic sudden sensorineural hearing loss
14. Meniere’s Disease and Related Disorders
Dae Hwan Kim
1
Byeong Min Lee1, Hyun Woo Park1, Seong-Ki Ahn1
1 Gyeongsang National University and University Hospital, Department of Otorlaryngology, South Korea
Purpose: Ménière’s disease is a clinical syndrome characterized by the four major symptoms of episodic vertigo, sensorineural hearing loss, tinnitus and aural fullness. Sensorineural hearing loss, especially low frequency, is the characteristic type of audiogram in Ménière’s disease.
We retrospectively analyzed the incidence of low frequency idiopathic sudden sensorineural hearing loss (ISSNHL) and progression of ISSNHL into Ménière’s disease.
Methods: We reviewed the medical records of 240 patients with ISSNHL from 2013 to 2015 retrospectively. The patients were 11 to 86 years old, 103 female and 137 male. These patients were divided into low, middle, high and all frequency hearing loss group according to type of pure tone audiogram. All patients received oral high dose oral corticosteroids therapy and low frequency hearing loss group was also given diuretics.
Results: In total 240 patients with ISSNHL were enrolled. 89 patients(37%) had hearing loss at low frequency, 5 patients(2%) at middle frequency, 43 patients(18%) at high frequency and 103 patients(43%) at all frequency. 14 patients(5.8%) were progressed to definite Ménière’s disease. In low frequency hearing loss group,13 patients(14.6%) were progressed to definite Ménière’s disease. In all frequency group, 1 patient(0.97%) was progressed to definite Ménière’s disease. The recovery rate of hearing was significantly higher in progressed group(70.3%) than in not progressed group(36.9%)
Conclusions: We should not overlook the possibility of progression to Ménière’s disease through accurate history taking and physical exam when low frequency hearing loss patients come, and we need to take appropriate evaluation and treatment accordingly.
PP2-24 - Intratympanic latanoprost for Menires - A randomized, double-blind, placebo-controlled study
14. Meniere’s Disease and Related Disorders
Mikael Karlberg
1
Per-Inge Carlsson2, Ylva Dahlin Redfors3, Cecilia Engmér Berglin4, Elsa Erixon5, Svante Hugosson6, Johan Knutsson7, Helge Lyckberg2, Claes Möller6, Serge Padoan8, Kristoffer Piekarek9, Michael Schulin10, Anette Sörlin11, Tatjana Tomanovic4, Lena Wiklund Snellman12, Fredrik Henell13
1 Lund University, Lund, Sweden
2 Karlstad Central Hospital, Karlstad, Sweden
3 Sahlgrenska University Hospital, Gothenburg, Sweden
4 Karolinska University Hospital, Stockholm, Sweden
5 Uppsala University Hospital, Uppsala, Sweden
6 Örebro University Hospital, Örebro, Sweden
7 Västerås Central Hospital, Västerås, Sweden
8 Kristianstad Central Hospital, Kristianstad, Sweden
9 Karlskrona Central Hospital, Karlskrona, Sweden
10 Linköping University Hospital, Linköping, Sweden
11 Sunderbyn Central Hospital, Luleå, Sweden
12 Falun Central Hospital, Falun, Sweden
13 Synphora AB, Stockholm, Sweden
Purpose: To assess the effects on hearing, tinnitus and vertigo of 1 or 3 intratympanic injections of latanoprost in patients with definite Meniere’s disease in a prospective, randomized, double-blind, placebo-controlled, parallel group study.
Two placebo-controlled cross-over studies in patients with long-standing Meniere have shown positive effects on hearing, tinnitus and vertigo after intratympanic latanoprost, a F2α-prostaglandin analogue commonly used to treat glaucoma, but the low number of patients made firm conclusions difficult.
Methods: 100 patients recruited at 13 swedish ENT-departments. Inclusion criteria: unilateral definite Meniere’s disease stage II-IV; speech discrimination < 85%; > 2 vertigo attacks during the previous 3 months. Patients randomized to 1 injection latanoprost 0.005% (n=27), 1 injection placebo (n=13), 3 injections latanoprost 0.005% (n=40) or 3 injections placebo (n=20) on 3 consecutive days. Before treatment there was a run-in period of 28-42 days.
Primary endpoint: speech discrimination score in noise (SDSN) at day 14 after first injection. Secondary endpoints: total number of vertigo/drop attacks during 3 months, SDSN, pure tone audiometry, Tinnitus Handicap Inventory (THI), subjective assessment of tinnitus, hearing and vertigo by Likert scales at Days 28, 42, 56 and 84.
Results: No significant differences between placebo and latanoprost in any of the endpoints. However, trends of improved hearing following 1 intratympanic injection as pure tone audiometry (all frequencies; 250 - 8 KHz) and SDSN, and a trend of an improvement in THI-score following 3 injections.
Conclusions: In perspective of the trends of both hearing and tinnitus improvements it appears logical to increase the exposure to latanoprost in a future clinical study.
PP2-25 - Low- & high-frequency VOR disparity may differentiate Menires disease from vestibular migraine
14. Meniere’s Disease and Related Disorders
Chun Wai Yip
1
Michael Strupp2
1 The National Neuroscience Institute, Singapore General Hospital Campus, Singapore
2 The German Center for Vertigo and Balance Disorders, University Hospital Munich, Campus Grosshadern, Germany
Purpose: The study primarily aims to evaluate how a “normal” video head impulse test (vHIT) plus unilateral/bilateral “abnormal” caloric irrigation can differentiate Menière’s disease (MD) from vestibular migraine (VM). Secondarily, this combination was applied to differentiate MD from other vestibular disorders.
Methods: Patients with unilateral MD, bilateral MD and VM who fulfilled the current diagnostic criteria were prospectively recruited. Patients with MD were symptomatic in the last 6 months. MD patients who had surgical or gentamicin treatment or overlapping VM/MD were excluded. Patients with various central and other peripheral vestibular disorders were recruited as comparators. All patients underwent complete diagnostic work-up, including vHIT and caloric testing. The test combination was applied to differentiate MD vs. VM, and MD vs. “others”. We defined normal vHIT gain >0.7, abnormal calorics = unilateral weakness >25 deg/s and/or sum of bilateral calorics < 10 deg/s.
Results: Unilateral MD (n=72) vs. VM (n=55): sensitivity 62.5%, specificity 81.8%, PPV 81.8%, NPV 62.5%. Bilateral MD (n=30) vs. VM: sensitivity 10%, specificity 100%, PPV 100%, NPV 67%.
Unilateral MD vs. “others” (n=521): sensitivity 62.5%, specificity 79.6%, PPV 29.8%, NPV 93.9%.Bilateral MD vs. “others”: sensitivity 10 %, specificity 98.3%, PPV 25%, NPV 95%.
Conclusions: The discrepancy between a normal vHIT and abnormal calorics is context-sensitive and is most useful for differentiating MD from VM (high specificity and PPV). In a mixed vestibular disorders setting, the high specificity and NPV also makes it a good screening test for MD.
PP2-26 - Menire and friends: Classification of Hydropic Ear Disease
14. Meniere’s Disease and Related Disorders
Robert Gürkov
1
Jeremy Hornibrook2
1 University of Munich, Otorhinolaryngology, Germany
2 Christchurch Hospital, Otorhinolaryngology, New Zealand
Purpose: More than 150 years after its initial description by Prosper Menière, the disease named after him is still in the centre of scientific debates. Two recent developments have specifically created a breeding ground for controversy: 1) The MRI diagnosis of endolymphatic hydrops in living patients. 2) The Bárány Society classification committee’s (BSCC) diagnostic criteria in 2015 proposed a concept of Menière’s Disease without endolymphatic hydrops. In order to promote the understanding of the underlying arguments, this presentation discusses relevant classification proposals for MD, including the new classification system of Hydropic Ear Disease.
Methods: The most influential MD classifications of the last decades are reviewed, and differences are highlighted. The recent proposal by the BSCC is reviewed and critically analyzed. The role of Endolymphatic Hydrops and other objective clinical tests for the diagnosis of MD is reviewed.
Results: Since 1995, the globally accepted standard was defined by the AAOHNS criteria for MD. The recent Barany classification committee proposal lacks precision and clarity in the description of the audiometric criteria. Furthermore, it negates the central role of Endolymphatic Hydrops. The novel concept of Hydropic Ear Disease reunites the cochlear, vestibular and cochleovestibular variants of MD and the primary as well as the secondary forms.
Conclusions: With today’s diagnostic possibilities - not only inner ear imaging - it is time to move from a subjective symptom based classification towards a classification including objective diagnostic tests. The concept of Hydropic Ear Disease provides a suitable framework to be used in high-tech as well as low-tech settings.
PP2-27 - Menires disease: combined pharmacotherapy with betahistine and the MAO B inhibitor selegiline
14. Meniere’s Disease and Related Disorders
Michael Strupp
1
Ludwig Kraus1, Franz Schautzer2, Dan Rujescu3
1 Ludwig Maximilians University, Munich, Campus Grosshadern, Department of Neurology and German Center for Vertigo and Balance Disorders (DSGZ), Munich, Germany
2 Landeskrankenhaus Villach, Department of Neurology, Villach, Austria
3 University Hospital Halle, Department of Psychiatry, Halle, Germany
Purpose: Since oral betahistine has a very high first-pass effect (ca. 99%), metabolized by monoamine-oxidases (MAO), the benefits of a high-dosage betahistine monotherapy were compared with those of a lower dosage of betahistine in combination with the MAO B inhibitor (MAO-B) selegiline on the frequency of acute attacks of vertigo in patients with Menière’s disease (MD).
Methods: Thirteen adults had initially been treated with a high dosage of betahistine-dihydrochloride for at least one year. Under this high dosage all of them had ≤ 1 attack for at least three months prior to the combination pharmacotherapy. Subsequently, the dosage of betahistine was reduced to about one tenth to one fifth and combined with 5 mg Selegiline.
Results: The initial dosage for the long-term “titration” of the attacks of vertigo was 216 – 1920 mg/d (mean 895.4 mg/d), after the combination it was 72 to 864 mg/d (mean 204.9 mg/d, p < 0.001 (paired t-test)) with the same therapeutic effect.
Conclusions: The achievement of the same clinical effect with a significantly lower (about 1/5) dosage of betahistine can be explained by the inhibition of the MAO-B by selegiline leading to higher serum concentrations of betahistine and – according to animal studies – for instance, by a dose-dependent increase of inner ear blood flow. Despite the substantial methodological limitations of such an observational study, a combined therapy could be an alternative to a very high-dosage monotherapy of MD with betahistine.
PP2-28 - P.M34T variant on GJB2 gene associated to familial deafness and Ménières disease
14. Meniere’s Disease and Related Disorders
Sergio Carmona
1
Guillermo Zalazar1, Guadalupe Méjico2, Santiago Revale3, María Fernanda Madeira4, María Florencia Gosso4, Bianca Brun5, Fabián Fay4, Martín Vázquez3
1 Neuro-otology. Fundacion San Lucas. Rosario. Argentina
2 CIBIC and Héritas. Rosario. Argentina
3 Héritas and INDEAR. Rosario. Argentina
4 Cibic and Héritas. Rosario. Argentina
5 Héritas and Indear. Rosario. Argentina
Purpose: The frequency of familial forms of Ménière’s disease is estimated in 7-15% according to several publications. The GJB2 gene pathogenic variant causes a cochleovestibular compromise that clinically manifests itself as hearing loss with vestibular compromise. In the family presented here affected subjects with clinical manifestations compatible with MD, fulfilling the current diagnostic criteria. We can state that this pathogenic variant is a candidate to be considered when evaluating patients with familiar Ménière’s disease.
Methods: Five members of a family with a family history of MD were assessed by whole exome sequencing. Of the five subjects that were studied, 3 were affected and 2 were asymptomatic.
Results: The variants obtained in whole exome analysis of the affected subjects (I-1, II-1 y II-2), an heterozygous mutation was detected in gene GJB2 (NM_004004.5:c.101T>C). The gene for conexine 26 (GJB2, MIM 121011), encodes protein CX26, which is part of a protein family that constitutes gap junctional channels and intercellular communication shown at the level of different inner ear structures (vascular stria, spiral prominence and spiral limbus of the cochlea). The main function of the CX26 channel in the inner ear structures is that of potassium ion homeostasis necessary for the hearing physiological mechanism. The GJB2 gene pathogenic variant causes a cochleovestibular compromise that clinically manifests itself as hearing loss with vestibular compromise. In the family presented here affected subjects with clinical manifestations compatible with MD, fulfilling the current diagnostic criteria.
Conclusions: This pathogenic variant is a candidate to be considered when evaluating patients with familiar Ménière’s disease.
PP2-29 - Pressure therapy of intractable Menieres disease using transtympanic membrane massage device.
14. Meniere’s Disease and Related Disorders
Hideo Shojaku
1
Hiromasa Takakura1, Michiro Fujisaka1, Masatsugu Asai1, Masahito Tsubota2, Yukio Watanabe1
1 University of Toyama, Department of Otolaryngology, Japan
2 Teikyo University Hospital, Department of Otolaryngology, Japan
Purpose: The effects of the TMM device were evaluated in patients with Meniere’s disease (MD) and delayed endolymphatic hydrops (DEH) according to the 1995 Japan Society for Equilibrium Research criteria.
Methods: Thirty-six ears of 30 patients were treated with the TMM device. All of the patients had failed to respond to medical treatment including diuretics prior to each pressure treatment, and were followed up for more than 24 months after treatment. The TMM device is an electrically controlled, low-pressure pulse generator that delivers pressure oscillating with a frequency of about 7 Hz. The tympanotomy is unnecessary for the TMM device. The intensity of the peak pressure can be controlled between -12cm H2O and +12cm H2O. The positive-negative pressure pulse are continuously delivered for 3 minutes.
Results: During the 19-24 month period after treatment, 24 of 30 patients experienced freedom from vertiginous spells; 3 patients responded with a significant decrease in frequency of definitive spells. In 3 patient, the definitive spells were unchanged by the TMM device, and then, the 2nd treatment was applied. As for the hearing outcomes in 19-24 month after treatment, 25 of 36 ears were classified into the unchanged. No complication was directly attributable to treatment by the TMM device.
Conclusions: Middle ear pressure treatment by the TMM device is an effective and minimal invasive option for intractable vertigo in the patients with the MD and DEH.
PP2-30 - Prognostic value of glycerol test of ECochG in patients undergoing sac decompression surgery
14. Meniere’s Disease and Related Disorders
Yupeng Liu
1
Jun Yang1
1 1.Department of Otorhinolaryngology-Head and Neck Surgery of Shanghai Xinhua Hospital affiliated to Shanghai Jiaotong University School of Medicine 2.Shanghai Key Laboratory of Translational Medicine on Ear and Nose Diseases 3.Ear Institute of Shanghai Jiaotong University School of Medicine
Purpose: The aim of this study is to determine whether the preoperative results of glycerol test of electrocochleography has a prognostic value on the effects of endolymphatic sac decompression surgery in patients with unilateral Meniere`s disease.
Methods: A retrospective case review study was conducted of 58 unilateral Meniere`s disease patients who underwent endolymphatic sac decompression surgery between 2003 and 2016. All of the patients underwent regular follow-up examinations for at least 2 years . The main outcome measures were vertigo control. The correlation between the preoperative results of glycerol test of electrocochleography and vertigo control was analyzed by Mann-Whitney-U-test.
Results: In 25 of 58 patients of positive glycerol test of electrocochleography, , according to AAO-HNS committee on hearing and equilibrium reporting guidelines, the vertigo control was Class A in 8 patients, Class B in 8 patients ,Class C in 4patients, Class D in 2 patients, Class E in 1 patients, Class F in 2 patients. In 33 of 58 patients of negative glycerol test of electrocochleography, the vertigo control was Class A in 4 patients, Class B in 7 patients , Class C in 8 patients, Class D in 9 patients, Class E in 2 patients, Class F in 3 patients. There was a significant difference between the two groups in vertigo control (P =0.026).
Conclusions: The present findings suggest that the positive preoperative results of glycerol test of electrocochleography may indicate a better effects of endolymphatic sac decompression surgery in patients with unilateral Meniere`s disease.
PP2-31 - Pure-tone follow-up study of Meniere’s disease
14. Meniere’s Disease and Related Disorders
Yi ZHANG
1
Bo LIU2, Suying GUO2
1 1Department of Otolaryngology Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing 100730, China 2Beijing Institute of Otolaryngology, Key Laboratory of Otolaryngology Head and Neck Surgery (Capital Medical University), Ministry of Education, Beijing 100730, China
2 1Department of Otolaryngology Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing 100730, China 2Beijing Institute of Otolaryngology, Key Laboratory of Otolaryngology
Purpose: Meniere’s disease is a progressive,disabling disease of inner ear. The aim of this study was to investigate the characteristics of hearing loss associated with Meniere’s disease.
Methods: forty-four patients who were diagnosed with definite unilateral Meniere’s disease at our Hearing and Vestibular Clinic were recruited in this study. As part of the protocol, audiometry was performed at the first visit, 3-month, 6-month and 12-month.
Results: Affected ears of patients show reduced hearing in pure-tone tests with average threshold of 39.81±19.58 dB HL.The majority of the patients (40.9%) were in Stage 3. The audiograms more frequently showed “ Upward-sloping”, “inverted ‘V’”, and “flat pattern”. Thirty-eight (86.4%)patients got improvement of 17.65±9.52dB HL after treatment . The average hearing threshoulds at 3-month, 6-month and 12-month after diagnosis were significantly better than that at fisrt visit(P0.01), and were not significantly different between each other. Patients with onset-age of more than 40 years old always get more severe hearing loss than that of below 40 years old (P0.01).Whether the onset-age is younger or older, both can get same amount of hearing improvements( P0.05). But the patients with older onset-age seem likely to get hearing redeclined after 12 months (P0.01).
Conclusions: Patients with definite Meniere’s disease always have moderate to severe sensorineural hearing loss before diagnosis. Most patients improved after treatment. Compared with the patients with younger onset-age, patients with older onset-age appear to have more severe hearing loss, but can get same-level hearing improvement after treatment, and tend to get hearing redeclined after 12 months.
PP2-32 - Revision surgery after triple semicircular canal plugging
14. Meniere’s Disease and Related Disorders
Daogong Zhang
1
Zhaomin Fan1, Yafeng Lv1, Yuechen Han1, Yawei Li1, Xiaofei Li1, Jing Wang1, Haibo Wang1
1 Department of Otorhinolaryngology Head and Neck Surgery, Provincial Hospital affiliated to Shandong University, Jinan, P.R. China
Purpose: To investigate the causes of vertigo relapse after triple semicircular canal plugging (TSCP) in patients with intractable Meniere’s disease (MD) and to explore the possible mechanism of post-TSCP vertigo in patients with MD
Methods: Eight patients with intractable unilateral definite MD who initially underwent TSCP and later experienced episodic vertigo recurrence, were enrolled. All eight patients underwent revision surgery, including four who underwent labyrinthectomy and four who underwent repeat TSCP. Audiological and vestibular functions were evaluated by pure tone test, caloric test, cervical vestibular evoked myogenic potential (cVEMP) and video-head impulse test (v-HIT). Morphological changes in the membranous labyrinth were assessed by magnetic resonance labyrinthography. Canal plugging materials and vestibular end organs (ampulla, saccule and utricle) were obtained from patients who underwent labyrinthectomy. Mineralization and other histological characteristics of canal plugging material were assessed by von Kossa staining.
Results: Incomplete occlusion and/or ossification was observed in the semicircular canals (SCs) of all eight patients, with the superior SC affected in five patients, the horizontal SC in one and all three SCs in two. The results of v-HIT, which reflected the respective function of the three SCs, were in accordance with intraoperative findings. Magnetic resonance labyrinthography showed semicircular canal defects in all eight patients.Few mineralized nodules and multiple cavities were present in the von Kossa-stained canal plugging materials.
Conclusions: Incomplete occlusion or ossification of SCs was the primary cause of vertigo recurrence following TSCP. v-HIT was useful, whereas magnetic resonance labyrinthography was limited, in determining the responsible SCs.
PP2-33 - The Detection of Endolymph Hydrops in the Patients using a Multifrequency Tympanometry
14. Meniere’s Disease and Related Disorders
Kazuhiko Kubo
1
Takamasa Yoshida2, Takashi Nakagawa1
1 Department of Otorhinolaryngology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, JAPAN
2 Department of Otorhinolaryngology and Neurotology, Chidoribashi General Hospital, Fukuoka, JAPAN
Purpose: Multifreqency tympanometry (MFT) is able to detect the change in the pressure of inner ear. The aim of this study was to compare the detection rate of the endolymph hydrops in the patients with Meniere’s disease (MD) and other diseases on G width (the width of bimodal peaks for the waveform obtained in measuring a conductance at 2000Hz) using MFT.
Methods: We have recruited 136 patients who complained vertigo or dizziness and were referred to our department. MFT measured G width at a resonance frequency of 2000Hz in all subjects. This word was approved by an ethics committee at Chidoribashi General Hospital.
Results: When the cutoff value was set at 200daPa, G width in the affected ears with MD and acute low-tone sensorineural hearing loss was significantly more elevated than that in the affected ears with benign paroxysmal positional vertigo and idiopathic sudden sensorineural hearing loss. Interestingly, no subjects had the elevated G width in the patients with such orthostatic dysfunction or functional hearing loss as non-inner ear diseases.
Conclusions: MFT is a noninvasive and easy device. These results suggest that MFT may be a useful tool to find out the endolymph hydrops of inner ear and to diagnose the patients exactly.
PP2-34 - The Effect of Intratympanic Dexamethasone for Sudden Sensorineural Hearing Loss
14. Meniere’s Disease and Related Disorders
Lu Hong
1
Dai QiaoMei1, Zhao Jing1, Shen FaJun1
1 Department of Otolaryngology, Shou Da ENT Hospital of Beijing, China
Purpose: The more and more otolaryngologists are pay close attention to the intratympanic injection for patient of the sudden sensorineural hearing loss, because the intratympanic injection can avoid blood-labyrinth barrier and have high drug concentration in the membrane labyrinth. the patient’s hearing recovering with the sudden sensorineural hearing loss by treatment of intratympanic Dexamethasone injection were observed in this paper.
Methods: Two groups were observed from Jan,2016 to Dec,2017.Observed group were 90 patients with the sudden sensorineural hearing loss by treatment of intratympanic Dexamethasone injection besides conventional therapy, Control groups were 120 patients with the sudden sensorineural hearing loss by treatment of conventional therapy no intratympanic Dexamethasone injection.
Results: Our research showed that hearing level recovering by intratympanic Dexamethasone injection were elevated than conventional therapy.
Conclusions: intratympanic Dexamethasone injection in early phase will be better method for patients of the sudden sensorineural hearing loss.
PP2-35 - The effect of transtympanic ventilation tube insertion in people with intractable
14. Meniere’s Disease and Related Disorders
Tessei Kuruma
1
1 Department of otorhinolaryngology, Aichi Medical University, Japan
Purpose: Transtympanic ventilation tube as a treatment option for Meniere’s disease has been reported but its results have been cotraversiol. As a treatment for patients with intractable Meniere’s disease, insertion of a ventilation tube in tympanic membrane was carried out, and the effect of the therapy was analysed.
Methods: Fourteen patients (nine males and six females, age ranged 15-79years) with active Meniere’s disease were placed with ventilating tubes in the affected ear and postoperative change in symptoms, i.e, incapacitating vertigo and hearing loss were investigated. The efficacy of treatment in vertigo attacks and hearing loss of this disease was evaluated according to AAO-HNS (1985) criteria.
Results: At 42 months of treatment, one of eight patients showed complete control of vertigo, and six did substantial and four insignificant control. On the other hand, patient’s hearing level was no affected by the treatment.
Conclusions: This treatment might represent a short term effect for the reduction of persistent vertigo in some patients with Meniere’s disease and so it might be an additional treatment option because of its simple and less-invasive procedure.
PP2-36 - The effect of transtympanic ventilation tube insertion in people with intractable Meniere’s disease
14. Meniere’s Disease and Related Disorders
Tessei Kuruma
1
1 Department of otorhinolaryngology, Aichi Medical University, Japan
Purpose: Transtympanic ventilation tube as a treatment option for Meniere’s disease has been reported but its results have been cotraversiol. As a treatment for patients with intractable Meniere’s disease, insertion of a ventilation tube in tympanic membrane was carried out, and the effect of the therapy was analysed.
Methods: Fourteen patients (nine males and six females, age ranged 15-79years) with active Meniere’s disease were placed with ventilating tubes in the affected ear and postoperative change in symptoms, i.e, incapacitating vertigo and hearing loss were investigated. The efficacy of treatment in vertigo attacks and hearing loss of this disease was evaluated according to AAO-HNS (1985) criteria.
Results: At 42 months of treatment, one of eight patients showed complete control of vertigo, and six did substantial and four insignificant control. On the other hand, patient’s hearing level was no affected by the treatment.
Conclusions: This treatment might represent a short term effect for the reduction of persistent vertigo in some patients with Meniere’s disease and so it might be an additional treatment option because of its simple and less-invasive procedure.
PP2-37 - The importance of temporal 3T MRI in the diagnostics of menieres disease in Lithuania
14. Meniere’s Disease and Related Disorders
Aiste Paskoniene
1
Vetra Markeviciute2, Eugenijus Lesinskas3
1 Clinic of Ear, Nose, Throat and Eye diseases, Institute of Biomedical Sciences, Faculty of Medicine, Vilnius University, Lithuania
2 Vilnius University, Faculty of Medicine
3 Vilnius University Hospital Santaros Klinikos, Ears, Nose and Throat Center
Purpose: Determine, whether the temporal 3T MRI could be a new objective criteria for Meniere’s disease diagnostics.
Methods: Prospective study was carried out at the VUH SK ENT center: the importance of temporal 3T MRI in the diagnostics of Meniere’s disease (MD) in Lithuania. The study included 81 patients with MD, diagnosed based on clinical criteria. Patients were divided into two groups, according to Subjective Diagnostic Criteria for MD formed by AAO-HNS and improved by Barany International Otoneurological Society. Patients were evaluated for endolymphatic hydrops using temporal 3T MRI with gadolinium contrast. Peripheral vestibular system and auditory examinations were also performed for all patients.
Results: Based on clinical criteria we diagnosed 81 patients with MD (probable MD -31 patients (38.3%, N = 81), and definite MD -50 patients (61.7%, N = 81)). Signs of endolymphatic hydrops were observed with MRI in 59 patients (72.8%, N = 81). Endolymphatic hydrops were detected in 45 (90%, N = 50) patients with definite MD and 14 patients (45.16%, N = 31) with probable MD. Changes in MRI (endolymphatic hydrops and the intensity of contrast accumulation) were observed in all 50 patients (100%, N = 50) with definite MD and 18 (58.06%, N = 31) with probable MD. Our methodology for MRI is clinically relevant to confirm the definite diagnosis of MD (P = 0.000019).
Conclusions: Therefore, the temporal 3T MRI could be one of the objective diagnostic criteria for MD.
PP2-38 - Treatment for intractable delayed endolymphatic hydropstriple semicircular canal plugging
14. Meniere’s Disease and Related Disorders
Yongkang Ou
1
1 Department of Otolaryngology-HNS, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, 107 Yanjiang west Rd, Guangzhou, 510120, China.
Purpose: Here, we explored the effectiveness of triple semicircular canal plugging for patients with intractable delayed endolymphatic hydrops
Methods: Five patients (1 females and 4 males, age 55 ± 4.95 years) with intractable ipsilateral delayed endolymphatic hydrops(DEH) were accepted treatment in our department from 2013 to 2017. Patients have taken the treatments of medication and Intratympanic injection for 9 months and showed no improvement on the attack of vertigo. All the patients were finally accepted surgery of triple semicircular canal plugging. After the surgery, the patients took audio-vestibular examinations and Imaging examinations during the 36 months follow up period.
Results: All the five patients were cured of their vertigo attacks after the surgery, and no postoperative recidivation was reported. Four patients showed residual hearing after the surgery. Hearing loss remain unchanged in 3 patients. One patient showed no response of operated ear in pure tone audiometry test. According to the results of caloric test, the degree of vestibular function deficit was enlarged in 5 patients. One patient was absent of reproducible waves in C-Vemp test after the surgery. The 5 patients complained about locomotion instability after the surgery, and improved their equilibrium ability through the 3 months vestibular rehabilitation treatment.
Conclusions: To reduce the symptom of vertigo, triple semicircular canal plugging is an effective surgical treatment for intractable delayed endolymphatic hydrops.
PP2-39 - Unilateral Menieres disease with downbeat nystagmus in 2 cases
14. Meniere’s Disease and Related Disorders
Dongzhen Yu
1
1 Shanghai Sixth People’s Hospital, Department of Otolaryngology, Shanghai
Purpose: The present study presented with 2 cases with Meniere’s disease who exhibited spontaneous nystagmus with downbeat component and the possible mechanism was analyzed.
Methods: The spontaneous nystagmus and provoked nystagmus by positioning tests in 2 patients with definite Meniere’s disease was retrospectively analyzed. The nystagmus induced by single or combined 2 or 3 semicircular canals’ excitation or inhibition was used to analyze the above nystagmus.
Results: 2 patients showed spontaneous downbeat nystagmus, which can be exaggerated by Dix-Hallpike maneuver. The vector sum of all unilateral semicircular canal excitation induced nystagmus can explain the downbeat nystagmus.
Conclusions: Downbeat nystagmus can be seen in Meniere’s disease.
PP2-40 - Vertical nystagmus during attacks of menieres disease or delayed endolymphatic hydrops.
14. Meniere’s Disease and Related Disorders
Pierre Bertholon
1
Yann Lelonge1, Pierre Reynard1, Alexandre Karkas1
1 Saint Etienne university hospital, France
Purpose: Spontaneous nystagmus during vertigo attacks of Menière’s disease or delayed endolymphatic hydrops has essentially been described as horizontal or horizonto-torsional beating either on the side or on the other side of the hearing loss. Our objective was to show videos of vertical nystagmus during vertigo attacks.
Methods: Patients suffered either from Menière’s disease (2 patients) or delayed endolymphatic hydrops (1 patient) and presented with an essentially vertical nystagmus (on videonystagmoscopy examination) during a vertigo attack.
Results: One patient with Menière’s disease had en essentially down beating nystagmus. Another patient with Menière’s disease had a fall (Tumarkin crisis) that occurred in the waiting room. Videonystagmoscopy, just after the fall, revealed a downbeating nystagmus with a slight rotatory component. During the crisis, the nystagmus later changed into a right horizontal nystagmus. The last patient had a history of delayed endolymphatic hydrops and an initial vertical upbeating nystagmus with a slight torsional component that later changed into a horizonto-torsional nystagmus.
Conclusions: The direction of the nystagmus during a vertigo attack can be essentially vertical which, to our knowledge, has never been reported in Meniere’s disease or DEH. This nystagmus might reflect an inhibition or excitation of the superior semicircular canal (on the side of the hearing loss) suggesting that the hydrops started in this canal. The nystagmus can be variable during avertigo attack and may later changed into a more typical horizontal or horizonto-torsional nystagmus.
PP2-41 - Vertigo and istamine: atopic reactions and histamin intolerance (HIT)
14. Meniere’s Disease and Related Disorders
Rosario La Gumina
1
1 Sciacca Hospital, ENT Department, Sciacca(Ag), Italy
Purpose: The potential etiopathogenetic link between intestinal hyper-permeability, psychogenic stress, histamine intolerance, migraine and pathology of the inner ear may represent a new line of investigation to explain the onset of a chronic and disabling pathology such as Meniere’s Disease
Methods: A clinical experience was conducted on a population of 65 patients (60 F, 5 M, age 15-50 years) with suspected histamine intolerance (HIT) associated with vertigo and/or fullness, postural disorders, sprain and / or diploacusia and hearing loss at low frequencies. Clinical tests have been conducted on the whole population, in particular Puretone Audiometry, ECochG by TM-Wick Electrode, C-Vemps, O-Vemps, VHIT (HIMP and SHIMP)
Results: Most of these patients presented altered Ecogh suggesting hydrops, pathological vHIT results in HIMP and SHIMP, of the lateral channel and some with altered OVEMP results, in the fluctuation phase, as well as altered cVEMPs. In the observed migraine patients, VHIT presented mono or bilateral over-gains, mono or bicanalar of the vertical and/or lateral channels, but over-gain was also found in subjects with Meniere during the fluctuation phase. All patients improved with rigid dietary patterns, characterized by reduced intake of histamine and with non-irritating foods for the intestinal mucosa, and an adequate control of body weight
Conclusions: Food education in menieric and migraine patient represents a heterodox approach useful to reduce food intolerances that through histamine-like, histaminergic reactions, IGE-mediated or not, due to histamine intolerance, promote systemic conditions of histamine increase (HIT) with mastocytosis and eusinophilia able to alter intestinal, cerebral and internal ear homeostasis, inducing migraine and vertigo
PP2-42 - Vestibular findings in patients with persistent apogeotropic nystagmus
14. Meniere’s Disease and Related Disorders
Tatjana Tomanovic
1
Johan Bergenius1
1 Department of Hearing and Balance Disorders Karolinska University Hospital, Stockholm, Sweden
Purpose: We have analyzed the characteristics of the non-paroxysmal nystagmus in patients with a heavy cupula in the lateral semicircular canal, irresistible to repositioning procedure.Two nystagmus patterns indicating the affected side has been reported; a) directional preponderance of the apogeotropic nystagmus towards the unaffected ear and b) nystagmus directed to the affected side in supination (ampullopetal cupula deviation).
Methods: The study comprised 26 patients (mean age 63 years) free from symptoms of CNS disorders. Patients were submitted to different tests at onset and at follow up (FU) without akut vestibular symptoms (20 patients). The nystagmus direction and slow phase velocity (SPV) with head in supine and prone position was studied. Connected to examinations the patients were submitted to caloric test and c-VEMP.
Results: Among 16 (62%) patients with caloric weakness, there was no significant correlation between side with caloric weakness and the direction of nystagmus in supine position. The median SPV for left beating nystagmus was 6°/s and for right beating nystagmus 5,5°/s. Nystagmus side difference exceeded 10°/s in four patients. At follow up thirteen of 20 (65%) patients demonstrated apogeotropic nystagmus with low value in SPV.
Conclusions: The affected side is difficult to judge, there is no consistent pattern between nystagmus in supine position and the directional preponderance of the apogeotropic nystagmus. There is no correlation between the direction of nystagmus in supine position and unilateral caloric weakness.
PP2-43 - A Case of Pendular Nystagmus: Delayed onset congenital nystagmus or acquired form by head trauma
15. Ocular Motility: Physiology and Pathology
Hak Seung Lee
1
1 Wonkwang University Hospital, Department of Neurology, South Korea
Purpose: Pendular nystagmus (PN) is characterized by quasi-sinusoidal oscillations of the eyes disrupting visual acuity and causing oscillopsia. PN can be classified into congenital and acquired form.
Methods: A 33-year-old man presented with binocular horizontal PN, dizziness and oscillopsia. These symptoms have been felt by the patient since the age of 20.
Results: In past medical history, the patient had no specific medical or surgical history, and the patient’s head was shocked by the traffic accident a few months before he felt the symptoms. The nystagmus was unaffected by convergence, vibration, head shaking, hyperventilation, or changes in body position. Brain MRI showed normal findings. Despite various drug treatments including memantine, there were no changes in patient symptoms and nystagmus. The congenital nystagmus (CN) occasionally presents during adult life, when it may create a diagnostic problem, especially if the patient has other symptoms such as headache or dizziness. Acquired PN may affect one or both eyes, and can occur in any axis or combination of axes. Although acquired PN may be idiopathic, the most common cause of secondary acquired PN is disorders of central myelin, namely multiple sclerosis (MS). Unfortunately, no abnormal findings were found in this patient, including various gene, blood and imaging studies. In addition, No PN has been reported after head trauma such as concussion.
Conclusions: Therefore, the author report a rare case of medication unresponsive PN and suggest that more research is needed.
PP2-44 - An Algorithm as a Diagnostic Tool for Central Ocular Motor Disorders
15. Ocular Motility: Physiology and Pathology
Ludwig Kraus1
Olympia Kremmyda1, Sebastià Barceló2, Tatiana Bremova1,
Michael Strupp
1
1 University Hospital LMU Munich, Department of Neurology and German Center for Vertigo and Balance Disorders, Germany
2 Syntax for Science, Palma de Mallorca, Spain
Purpose: To create an algorithm which can assist physicians as a “digital expert” with the diagnosis of central ocular motor disorders, in particular due to lesions and the brainstem and cerebellum, which are often associated with vertigo or dizziness.
Methods: The algorithm’s input consists of a maximum of 60 neurological and oculomotor symptoms. The output is a list of the most probable diagnoses out of 14 alternatives and the most likely topographical anatomical localizations out of 8 alternatives. Positive points are given for disease-associated symptoms and negative points for symptoms that are unlikely to be found in a specific disease. The algorithm was evaluated using the two diagnoses and two brain zones with the highest scores. A dataset of 102 patients (56 males, age 48.0 ±22yrs) was used as the basis for developing the algorithm in an iterative way. In a second step, the algorithm was validated with a dataset of 104 patients (59 males, age 46.0 ±23yrs).
Results: For 12/14 diseases the algorithm showed a sensitivity between 80 and 100% and the specificity of 9/14 diseases was between 82 and 95%. In terms of a topographic anatomical diagnosis, the sensitivity was between 77 and 100 % for 4/8 brain zones, and the specificity of 5/8 zones ranged between 79 and 99%.
Conclusions: This algorithm using our knowledge on the functional anatomy of the central ocular system and possible underlying diseases is a useful tool, in particular for the diseases affecting the brainstem or cerebellum which are otherwise often overlooked.
PP2-45 - Living in the dark: self-induced visual deprivation leading to pendular nystagmus.
15. Ocular Motility: Physiology and Pathology
Diego Kaski
1
Parashkev Naschev2, Rolf Jager3, Magdalena Sokolska3, Gary Zhang3, Manjit Matharu2
1 Sobell Department of Motor Neuroscience and Movement Disorders, University College London, London, UK
2 Department of Neurology, National Hospital for Neurology and Neurosurgery, London WC1N 3BG
3 Department of Neuro-radiology, University College Hospital London, NW1 2BU
Purpose: To describe the case of a patient with a background history of chronic migraine, who developed continuous nystagmus following prolonged visual deprivation, resolving following light re-exposure.
Methods: A 64-year-old right-handed artist with chronic migraine associated with marked photophobia and phonophobia, refractory to multiple preventative medications, neuromodulators (including the Gammacore, Cefaly and TMS), acupuncture, greater occipital nerve blocks and multiple cranial nerve blocks. More recently her headaches have been partially controlled with intravenous Magnesium Sulphate and Botox injections. In view of the marked photophobia she has confined herself to the dark for the last 4 years, achieved by living in a blacked-out house with the only illumination being from a small camping light set to a nocturnal mode, and using a set of two eye occluders when leaving the house. She presented with progressive torsional and horizontal oscillopsia when viewing in low-level lighting conditions. She was found to have rotational nystagmus in the primary position and on lateral gaze, with otherwise normal pursuit, saccades, and OKN.
Results: We report detailed audiovestibular investigations and functional brain MRI, including arterial spin labelling and NODDI. We show functional visual pathway deafferentation and propose that this developed secondary to self-induced visual deprivation. We report imaging changes following gradual light re-sensitisation, correlating with clinical outcome.
Conclusions: We discuss possible underying mechnisms to explian the development of nystagmus following self-imposed visual deprivation. We consider inferior olive deafferentation secondary to visual deprivation, affectation of brainstem neural integrators, unmasking of a congenital nystagmus, and a light-dependent feedback loop.
PP2-46 - Long-term course of progression of clinical ocular motor signs in progressive supranuclear palsy
15. Ocular Motility: Physiology and Pathology
Andreas Zwergal
1
Florian Schöberl1, Ken Möhwald2, Günter Höglinger3, Thomas Brandt4, Marianne Dieterich1
1 Ludwig-Maximilians-University Munich, Department of Neurology, German Center for Vertigo and Balance Disorders (DSGZ)
2 Ludwig-Maximilians-University Munich, Department of Neurology
3 Technical University Munich, German Center for Neurodegenerative Diseases (DZNE)
4 Ludwig-Maximilians-University Munich, Clinical Neurosciences, German Center for Vertigo and Balance Disorders (DSGZ)
Purpose: To investigate the natural course of progression of ocular motor signs in patients with progressive supranuclear palsy (PSP).
Methods: 114 patients with a possible or probable PSP following NINDS-SPSP criteria were included in this retrospective study. All patients underwent structured neuro-ophthalmological testing at initial diagnostic evaluation, 35 patients several times during their course of disease. The following ocular motor signs were analysed: Saccadic slowing/paresis in vertical/horizontal direction, up-/downward/horizontal ocular motility, square wave jerks, VOR-function. Ocular motor signs were investigated in relation to disease duration.
Results: In the whole group of PSP patients saccadic abnormalities showed the following distribution over time: at 1y of disease duration 10% showed only saccadic slowing on upgaze, 40% on up- and downgaze, 21% saccadic paresis on upgaze and 29% complete vertical saccade paresis; at 2y the proportion of vertical saccade paresis was 32%, at 3y 65% and at 4y 82%. Progression of horizontal saccade paresis was slower (1y: 6%, 2y: 9%, 3y: 21%, 4y: 41%). The subgroup of patients with longitudinal follow-up showed a similar tendency. Ocular motility in this group decreased by a mean of 1.5mm/y on upgaze, 1.6mm/y on downgaze and 1.4mm/y on horizontal gaze. The degree of motility loss on up-/downgaze over time showed a good correlation (R2=0.71).
Conclusions: Ocular motor examination can be used as a robust marker of disease progression. Variability between patients however is considerable. Prospective clinical and apparative quantification of ocular motor markers in well-characterized cohorts of PSP patients is needed.
PP2-47 - Rebound nystagmus, a window to the oculomotor integrator
15. Ocular Motility: Physiology and Pathology
Jorge Otero-Millan
1
Ayse I. Colpak2, David S. Zee1, Amir Kheradmand1
1 Johns Hopkins University, Neurology, USA
2 Hacettepe University, Neurology, Turkey
Purpose: Accurate and stable gaze holding is achieved by the oculomotor integrator, a complex network within the brainstem and cerebellum. Adaptation of this network can result in rebound nystagmus when looking straight ahead after holding eccentric gaze. Rebound nystagmus, typical in cerebellar dysfunction, also occurs in healthy individuals. Here we studied whether rebound nystagmus was influenced by fixation at the eccentric position or by the eye movement used to move eccentrically.
Methods: We recorded eye movements of 6 healthy subjects in darkness looking at a red target, which was on continuously or flashed 10ms every 500ms. In experiment 1, subjects fixated a continuous or flashing target at ±40° for 30s, then a central flashing target for 15s. In experiment 2 a continuous eccentric target was reached with smooth pursuit, single saccade, or ten small saccades.
Results: We found more pronounced rebound nystagmus after continuous than flashing peripheral target and no change regardless of how the eyes moved eccentrically. The intensity of nystagmus decreased between first and fifth trial. In some subjects, was asymmetric depending on the direction of gaze holding and could reverse direction during central fixation.
Conclusions: Rebound nystagmus offers an opportunity to study the adaptive mechanisms of the gaze holding networks. Because the continuous target generated a more robust rebound nystagmus, we hypothesize that a retinal slip (i.e., velocity) signal is at least partially responsible for rebound nystagmus. Future experiments and modeling studies will determine the relative contribution of velocity vs. position signals.
PP2-48 - Vertical Component of Horizontal Nystagmus due to Impairment of Vertical Semicircular Canals
15. Ocular Motility: Physiology and Pathology
Maja Striteska
1
Michal Janouch1, Jan Mejzlík1, Peter Sila1, Jakub Drsata1
1 Department of Otorhinolaryngology and Head and Neck Surgery , University Hospital Hradec Kralove
Purpose: The purpose of the study was to evaluate a vertical or torsional component of horizontal spontaneous nystagmus in acute vestibular lesions according to damage in vertical semicircular canals.
Methods: Retrospective study, 32 patients involved (28 peripheral, 4 central), inclusion criteria - presence of spontaneous nystagmus (SPN). VOG (Videooculography) measures the slow phase velocity (aSVP), the number of beats. VHIT (Video Head Impluse Test) measures the gain of vestibuloocular reflex, under 0.70 in vertical canals is pathological (also corrective saccades).
Results: The direction of the nystagmus corresponded with the VHIT results. The damage of the lateral canal provokes the main – horizontal – direction of the nystagmus. The damage in vertical canals provokes the measured vertical component . The vertical portion is also determined with a slow phase and fast phase. A lesion of anterior SCC provokes the up-beating component, and a lesion of posterior SCC provokes the down- beating component. The vertical component of the horizontal nystagmus is common in peripheral vestibular lesions (PVS) as well as in some cases of central vestibular lesions (CVS). The main direction of the nystagmus of peripheral origin was horizontal with an up-beating portion due to the most frequent diagnosis of superior vestibular neuronitis. The PVS or CVS that affect all 3 canals, had often rather a torsional than vertical component, or changing up/down component, or only horizontal direction.
Conclusions: In vestibular lesions, the vertical component of the horizontal nystagmus is a common condition. This up- or down-beat component correlates with the damage of the anterior or posterior canal function.
PP2-49 - Two case reports of perilymphatic fistula after nose blowing with review of possible mechanisms
16. Perilymphatic Fistula
Eun Jung Lee
1
Min Hee Lee2
1 Dep otolaryngology Chonbuk National University Hospital in Jeon ju, South Korea
2 Subdivision of pulomology, Dep. of intenal medicine, Presbyterian Medical Center in Jeon ju, South Korea
Purpose: We report two cases of perilymphatic fistula after nose blowing without trauma. In both cases, the symptom of the patients resolved spontaneously after conservative treatment. We report the cases with review of possible mechanisms of perilymphatic fistula
Methods: A 15-year-old female presented with dizziness after excessive nose blowing. It had been 2 days before visiting to clinic. Associated symptoms were nausea, tinnitus and fullness on the left ear. The physical examination including otoscopic exam and vestibular function test found to be normal. Pure tone audiometry showed 22dB of bone, 14dB of air conduction on the left ear. The high resolution temporal bone CT scan was done which documented multiple air densities in left vestibule. A 46-year-old female visited with hearing impairment with tinnitus on left ear after same event of the first patient which started 4 days before. There was no pathologic finding on physical examination. The result of pure tone audiometry was left sid air conduction of 31dB, bone conduction of 29dB. High resolution temporal bone CT scan noted to be normal.
Results: The clinical result of hearing loss and CT scan was highly suggested of perilymphatic fistula. Both patients were given high dose steroid and broad spectrum antibiotics. Gradual improvement of hearing symptom was seen. The result of pure tone audiometry each 8, 10 days after admission was improved.
Conclusions: Based on two different cases, perilymphatic fistula which occurred by excessive pressure change in inner ear can be treated by conservative treatment.
PP2-50 - A prospective study of Cochlin-tomoprotein detection test in sudden sensorineural hearing loss cases
16. Perilymphatic Fistula
Akira Sasaki
1
Tetsuo Ikezono2, Han Matsuda2, Ikuko Takeda1, Atsushi Matsubara1
1 Hirosaki University Graduate School of Medicine, Department of Otorhinolaryngology, Japan
2 Saitama Medical University Faculty of Medicine, Department of Otorhinolaryngology, Japan
Purpose: Sudden sensorineural hearing loss (SSNHL) occurs as an unexplained, rapid loss of hearing and concomitant vestibular symptoms. In general, 20~50% of SSNHL has vestibular symptoms. Various theories have been proposed for the cause of the disease including viral infection, vascular insufficiency, and perilymphatic fistula (PLF). PLF has been a controversial disease entity but recent proteomic and molecular analysis identified a novel diagnostic marker CTP (Cochlin-tomoprotein) to detect perilymph leakage. CTP detection test from middle ear lavage (MEL) is available in 170 hospitals throughout Japan and it dramatically changed the current status of the diagnosis of PLF (Matsuda H, Acta Otolaryngol 2017). The purpose of this prospective study is to elucidate the prevalence of PLF in SSNHL patients and to characterize the clinical characteristics of those cases.
Methods: According to the inclusion/exclusion criteria, 104 SSHL cases were enrolled and 74 cases were subjected for analysis. For CTP testing, we performed myringotomy by a CO2 laser, the middle ear was rinsed with 0.3ml saline, middle ear lavage (MEL) was collected. Polyclonal antibody ELISA (hCTP ELISA) was performed (Ikezono T, PLos one 2018).
Results: CTP was positive in 16 out of 74 cases (22%). The incidence of CTP positive case was higher in the elderly and a significant correlation between age and CTP values was recognized. Patients with CTP positive cases had higher tendency to complain of vestibular problems (63%) than those with CTP negative cases (48%).
Conclusions: Our study delineated that PLF can be one of the main causes of SSNHL especially in the elderly.
PP2-51 - Proposal of the diagnostic criteria for barotraumatic perilymph fistula (PLF)
16. Perilymphatic Fistula
Jungmin Ahn
1
Se Eun Son1, Won-Ho Chung1
1 Department of Otorhinolaryngology-Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
Purpose: The aim of this study was to propose the diagnostic criteria for PLF based on clinical manifestations.
Methods: Forty-four patients (46 ears) who underwent surgical repair by the clinical suspicion of barotraumatic PLF were enrolled. The clinical symptoms and hearing improvement were analyzed according to the surgical findings.
Results: Eighteen of the patients (definite PLF) was confirmed by the evidence of perilymph leak through the oval and round window via surgery. For the other twenty-one patients (probable PLF), even though there was no evidence of perilymph leak, their clinical manifestations were similar to definite PLF. In addition, the cases that were satisfied at least two of 3 criteria (hearing loss, dizziness and preceding barotraumatic history) in probable PLF was identified in 5 patients (possible PLF). After surgical repair of PLF, the hearing was improved in 28 out of 44 patients when hearing improvement defined as postoperative 4-frequency pure tone average (0.5, 1k, 2k, and 4kHz) of bone conduction ≤ 25dB or hearing gain ≥ 15dB. Hearing improvement was also identified in 4 of the possible PLF patients after early surgical exploration. The period of operation after symptom onset was significantly (p < 0.05) shorter in the hearing improvement group (mean 6.7 days; range 1-17 days) than that in the no improvement group (mean 108 days; range 1-671 days).
Conclusions: We proposed the diagnostic criteria of barotraumatic PLF as definite, probable, and possible PLF. Once the barotraumatic PLF was suspected, hearing and dizziness were improved by early surgical repair.
PP2-52 - Oxidative stress in leukoaraiosis dizziness patients, effect of a polyphenol supplementation
17. Pharmacotherapy
Augusto Pietro Casani1
Elena Navari1, Leonardo Ulivi2, Michelangelo Mancuso2
1 Pisa University Hospital, ENT Section, Italy
2 Pisa University Hospital, Neurology Section, Italy
Purpose: Leukoaraiosis (LA) is a common radiological finding in elderly, frequently associated with several clinical disorders, including unexplained dizziness. Aim of this study was to analyse some oxidative stress biomarkers in patients with LA and unexplained dizziness, and to perform an open study to evaluate if 60-day supplementation with a poliphenol compound may modify these biomarkers and influence quality of life.
Methods: a cohort of 33 patients were enrolled in the study and studied basally and after 60-day poliphenol compound supplementation. The main outcome measure were: oxidative stress markers (advanced oxidation proteins products, AOPP, ferric reducing antioxidant power, FRAP), and Thiols and the Dizziness Handicap Inventory (DHI) scale.
Results: At baseline, blood oxidative stress parameters values were outside normal ranges. After the two months supplementation, we observed a significant decrement of AOPP values and a significant improvement of DHI.
Oxidative stress load was not influenced by age, gender, hypertension, diabetes, smoking or dyslipidemia. No relation was found between chronic ischemic burden evaluated at CT or MRI scans and oxidative stress biomarkers.
Conclusions: patients with LA and dizziness have an impaired oxidative stress balance. Oxidative stress biomarkers may be useful to detect redox imbalance in LA and to provide non-invasive tools to monitor disease status and response to therapy. The supplementation with poliphenol compound reduces oxidative stress load in patients with a pre-existing imbalance, and seems to improve dizziness symptoms. Oxidative stress biomarkers may be useful to detect redox imbalance in LK and to provide non-invasive tools to monitor disease status and response to therapy.
PP2-53 - Acute topographical disorientation due to right-sided hippocampal haemorrhage
18. Spatial Orientation
Stephanie Irving
1
Cauchy Pradhan1, Marianne Dieterich1, Thomas Brandt1, Andreas Zwergal1, Florian Schöberl1
1 University Hospital Munich, Department of Neurology and the German Centre for Vertigo and Balance Disorders, Germany
Purpose: Acute presentations of topographical disorientation are rare and mostly caused by focal lesions in the cerebral navigation network. Deficits are predominantly in landmark recognition and path planning (egocentric navigation deficit), or a disturbance of the spatial cognitive map (allocentric navigation deficit). Here we report the spatial orientation performance in a 55-year old patient with isolated topographic disorientation as the single symptom of right-sided hippocampal haemorrhage, and the follow-up performance 4 months later.
Methods: Utilising a gaze-monitoring head camera, we analysed the path-finding strategy and visual exploration behaviour in a real-space environment navigation paradigm. The patient was shown the location of five target items, and subsequently had to relocate items in a pseudo-randomised order. Parameter analyses included saccades and fixations, error rates in item location, time spent at crossroads, trajectory, and were compared with a healthy cohort (N=10). The experiment was repeated four months later, upon recovery. MRI was obtained upon admission and four months later.
Results: The patient had severe allocentric and egocentric navigation deficits on admission, as indicated by higher error rates, extensive use of search saccades, and fixations to landmarks. These deficits recovered after 4 months, when the patient performed above-average in the real-space navigation task.
Conclusions: This case report underlines the integral function and right-sided dominance of the hippocampal formation in spatial orientation, where a strategic lesion causes a profound navigational deficit. We show that navigation, specifically allocentric navigation, can be fully restored despite a residual hippocampal lesion, illustrating the neural plasticity of the cerebral navigation network.
PP2-54 - Astronauts Gaze Behavior during Visual Target Acquisition during and after Space Shuttle Flights
18. Spatial Orientation
Ognyan I. Kolev
1
Gilles Clement2, Millard F. Reschke3
1 Neuroscience Laboratories, NASA Johnson Space Center, Houston, TX, USA; University Hospital of Neurology and Psychiatry, Sofia, Bulgaria
2 Lyon Neuroscience Research Center, Bron, France; KBRwyle, Houston, TX, USA
3 Neuroscience Laboratories, NASA Johnson Space Center, Houston, TX, USA
Purpose: We aimed to explore how exposure to weightlessness changed gaze behavior and eye-head coordination during the acquisition of visual targets during and after orbital space flight.
Methods: Using a forced time optimal strategy thirty-four astronauts were required to acquire as quickly as possible targets with angular offsets of ±20, ±30 and ±49° in the horizontal plane. Eye movements were measured with electro-oculography. Head movements were measured with a triaxial rate sensor system mounted on a headband.
Results: Measurements of eye, head and gaze movement duration, amplitude, velocity and acceleration during visual target acquisition in weightlessness indicated changes in eye-head coordination strategies that varied across target distances. Changes also varied as a function of flight days.
Conclusions: The changes in eye-head coordination inflight are presumably the result of a combination of several factors. These factors could include the change from allocentric to egocentric reference for spatial orientation in absence of a gravitational reference, the generation of slower head movements to prevent space motion sickness, and a decrease in smooth pursuit and vestibulo-ocular reflex performance. These results are in agreement with the hypothesis that humans have several strategies for gaze behavior, between which they are able to switch depending on the environmental conditions.
PP2-55 - Body-based spatial reasoning selectively disrupted by vertigo after a decelerating velocity step
18. Spatial Orientation
Jeremy Corcoran
1
John Golding1, Anthony Towell1, Mark Gardner1
1 University of Westminster, Department of Psychology, London
Purpose: Spatial reasoning has been found to be the cognitive faculty most impaired by misperceptions of self-motion. The objective of this study was to determine whether vertigo, elicited by a standard velocity step in a motorised rotating chair, selectively impacts different spatial reasoning processes.
Methods: Seventy-eight healthy participants undertook the ‘Single Figure Stimuli’ (SFS) task, invoking body-based mental rotations, the ‘Dual Figure Stimuli’ (DFS) task, invoking object-based mental rotations, or the ‘Single Object Stimuli’ (SOS) task, requiring non-rotational, rule-based responses. The SFS and SOS tasks had equivalent difficulty. All spatial reasoning tasks were administered six times, in one-minute trial blocks, after one minute of constant angular velocity (90°/s). Halfway through alternating trial blocks, chair velocity reduced from 90 to 0°/s in 4.5 seconds. Participants wore wireless heart rate monitors throughout.
Results: Performance on the DFS and SOS tasks was not affected by the velocity step. In contrast, error rate on the SFS task was significantly greater during the 30 seconds after impulse deceleration (5.4%) than after zero deceleration (3.4%), p = .028. There was no effect of the velocity step on Heart Rate Variability (HRV), hence on autonomic balance, in any of the task groups.
Conclusions: The confined disruption of performance on the SFS task following the velocity step indicates a selective vulnerability of body-based spatial reasoning to vertigo induced by incongruous vestibular stimulation. Moreover, the absence of autonomic changes following the velocity step suggests there is a direct coupling between self-motion perception and simulated body-based action.
PP2-56 - Changes in Heart Rate Variability due to Continuous Stimulation in the Head with a mini-Vibrator
18. Spatial Orientation
Mi joo KIM
1
Mi Seon AN1, Jiyeon LEE1, Gyu cheol HAN2
1 Catholic Kwandong University International ST. Mary’s Hospital / Department of Otorhinolaryngology
2 Gachon University of Medicine and Science, Graduate School of Medicine / Department of Otolaryngology-Head and Neck Surgery
Purpose: No vestibular exercise or Vestibular implant has been tried for afferent signal restoration of the otolithic organ. This is because the quantitative input stimulation of the otolithic organ and the measurement of the effector are incomplete. Hypergravity, based on previous experiments to induce degeneration of otoconia itself, was intended to investigate whether sustained otolithic organ vibration stimulation could prevent such hypergravity changes.
Methods: Subjects were divided two groups, as normal and experimental group. All animal were fixed the miniature vibrator to the head under general anesthesia. Experimental group included an ICR mouse that lived for 7 days under 4G hypergravity environment. We then recorded the ECG to measure heart rate variability as control of an otolithic autonomic reflex.
Results: Compared to control group, the Heart rate of the experimental group was significantly decreased (p <0.01), and the change of the heart rate before and after vibration stimulation was 4.3 ± 0.232, which was significantly higher than the 2.5 ± 0.232 of the control group.
Conclusions: Although the action mechanism of stimulation has not been elucidated, vibration as an input signal modulator, it can not be denied that the otolithic organ will be affected. The vibration stimulation increased the heart rate in mice with reduced otolithic function, confirming the possibility of a functional modulator of the otolithic organ.
PP2-57 - Comparison of Haptic and Visual Perception of Upright and the Effect of Handedness
18. Spatial Orientation
Jorge Otero-Millan
1
Min Jung Kim1, Shirin Sadeghpour1, Amir Kheradmand1
1 Johns Hopkins University, Neurology, USA
Purpose: Perception of upright depends on multisensory integration including vestibular, visual and proprioceptive inputs. Here we studied systematic biases in upright perception measured by visual and haptic modalities. We also investigated the role of laterality in cerebral function on measurements of upright perception in each modality.
Methods: Subjects performed three tasks comparing a visual line with perceived upright (visual-vertical), a haptic bar with perceived upright (haptic-vertical), and a visual line with a haptic bar (visual-haptic). All tasks were repeated in three head tilt positions: upright and 20° tilted to the right and left. The haptic task was repeated using the left and right hands.
Results: Regardless of the task, upright perception was biased by the head tilt position. In the haptic task, there was an independent bias by the hand used to touch the haptic stimulus. We dissociated the effects of hand and spatial location of the haptic stimulus by repeating the task with the haptic bar at the midline. The results showed that the hand bias was indeed from the effect of the hand itself rather than the spatial location of the haptic bar. Both head and hand also had similar effects when the task did not involve vertical measurement (i.e., the visual-haptic task). Finally, there was no difference in the hand and head biases between left-handed and right-handed subjects in either visual or haptic tasks.
Conclusions: Our findings show that systematic biases in visual and haptic vertical measurements can be dissociated, suggesting a common mechanism for perception of upright.
PP2-58 - Cortical integration of vestibular and visual inputs during forward self-motion
18. Spatial Orientation
Alexandra Séverac Cauquil
1
Philippine Picher1, Maxime Rosito1, Simona Celebrini1, Benoit R Cottereau1
1 CerCo, CNRS, Université Toulouse III, France
Purpose: It is crucial to characterize the cortical networks that integrate vestibular and visual signals, the main sensory inputs during navigation. In a previous work, we used Galvanic Vestibular Stimulation (GVS) and functional Magnetic Resonance Imaging (fMRI) to show that visual areas V6 and the ventral intraparietal (VIP) area are activated by locomotion-consistent, anteroposterior vestibular inputs. Here we combined binaural monopolar GVS with optic flow visual stimuli that were either consistent with forward (expanding flow) or backward (contracting flow) self-motion.
Methods: Our GVS had an amplitude of 1.5mA, lasted 2s, for the 2 polarities, either forward or backward. We recorded the BOLD responses to different congruent and incongruent combinations of these visuovestibular stimuli in 5 human subjects. We focused our analyses on responses within functionally-defined areas that are strongly activated by egomotion-consistent optic flow patterns: the human middle temporal complex (hMT+), V6, the ventral intraparietal (VIP) area, the cingulate sulcus visual (CSv) area and the posterior insular cortex (PIC).
Results: The contrast between bimodal (ie vestibular and visual) vs monomodal, (ie visual only) conditions revealed significantly stronger activations in areas V6 and PIC, and to a lesser extent in area CSv. This was found for both congruent and incongruent designs. Interestingly, area VIP was significantly more activated during congruent versus incongruent conditions in 3 out of 5 subjects.
Conclusions: Altogether, our results suggest that anteroposterior self-motion is integrated within a cortical network that includes non-specific bimodal areas (V6, PIC, and CSv) and an area that more particularly processes congruent visuo-vestibular inputs (VIP).
PP2-59 - Effects of space perception on unilateral vestibular loss mice
18. Spatial Orientation
Gyu Cheol Han
1
Jiyeon LEE2, Mi Seon AN2, Mi joo KIM2
1 Gachon University of Medicine and Science, Graduate School of Medicine / Department of Otolaryngology-Head and Neck Surgery
2 Catholic Kwandong University International ST. Mary’s Hospital / Department of Otorhinolaryngology
Purpose: Space perception and direction of locomotion are based on direction & place cell and short term memory of hippocampus. All information regulated in the hippocampus is based on visual input and vestibular information. Therefore, the change of the vestibular function causes distortion of the object’s space perception and decision of locomotion. To demonstrate this, a behavioral test using Y-Maze was performed on semicircular canal and otolithic organ destroyed animal models.
Methods: The Y-maze test was performed by dividing the otolithic organ function changing group (n = 10) and a labyrinthectomy group (n = 10, POD #3). The information obtained from the Maze test was coded as the order of selection from each arm to the other of maze, and finally the dominancy of left-right side was calculated as %.
Results: The otolithic function changing group had no dominancy of the left-right side regardless of centrifuge direction (p> 0.05), and the locomotion selection dominance was observed in the labyrinthectomy group toward the vestibular loss.
Conclusions: In the Hippocampus, space-related information processing seems to be determined by semicircular canal information rather than otolithic organ.
PP2-60 - Effects of vestibular disorders on vestibular reflex and imagery
18. Spatial Orientation
Bernard Cohen
1
Joëlle Provasi2, Pierre Leboucher3, isabelle Israël4
1 ENT department, Hôpital Saint-Antoine - Sorbonne Université, Paris, France
2 Laboratoire CHArt, EPHE-PSL, Paris, France
3 PRISME, ICM, CNRS UMR 7225, Hôpital Pitié-Salpêtrière, Paris, France
4 Laboratoire Cognac G, CNRS UMR 8257, Paris, France
Purpose: The aim of this study was to establish the effect of vestibular lesion on vestibular imagery. Subjects were required to estimate verbally their passively travelled rotation angles in complete darkness, i.e., to activate vestibular imagery. During motion the Vestibulo-Ocular Reflex (VOR) was measured. Thus we examined the cohérence between the vestibulo-ocular reflex and self-rotation imagery, with vestibular-lesioned patients and healthy participants.
Methods: Unilateral acute and chronicle patients, bilateral patients and healthy subjects were compared. The stimulus was a sequence of eight successive passive rotations, with four amplitudes (from 90° to 360°) in two directions.
Results: The VOR gain was lower in patients with unilateral lesions, for ipsilateral rotations. The healthy subjects had the highest gain and the bilateral group the lowest, on both rotation sides. Thanks to vestibular compensation after acute unilateral neuritis the VOR gain increased in lesion side and decreased in healthy side, resulting in a similar gain in both sides. A deficit of vestibular imagery was found exclusively in patients with bilatéral hyporeflexia, on both sides. The performance in vestibular imagery was good in the control group and correct in the unilateral patients.
Conclusions: Finally we found a significant correlation between the efficiency of VOR and that of vestibular imagery, exclusively in the bilateral patients.
The present study shows the complex relationship between vestibular imagery and the VOR. This imagery test contributes to another assessment of the spatial handicap of vestibular patients. It seems particularly interesting for patients with bilateral canal paresis and could be used to confirm this diagnosis.
PP2-61 - Impact of alcohol on self-motion perception and reflexive eye movements: the role of the cerebellum
18. Spatial Orientation
Fausto Romano
1
Dominik Straumann1, Giovanni Bertolini1
1 University of Zurich, Department of Neurology, Switzerland
Purpose: Acute alcohol intoxication is well-known to alter the performances of visual and vestibular systems at different levels of signal processing, from reflexive responses to spatial orientation. However, how alcohol interferes with the processing of the visual-vestibular integration is still an open question. We hypothesized that alcohol-induced disorientation is due to a detuning of the multisensory integration process responsible for merging self-motion cues.
Methods: To test our hypothesis, we compared reflexive and perceptual responses of twelve healthy subjects before (BA) and 30min after (AA) intake of the estimated amount of alcohol needed to reach BAC of 0.06%. Specifically, a passive sustained yaw-rotation at 90°/s for 60s were delivered to test vestibulo-ocular reflex (VOR) and perceived rotational velocity (PRV), while a constant yaw-rotation of an optokinetic drum at 30°/s for 60s was provided to measure the optokinetic after-nystagmus (OKAN) and the generated circularvection.
Results: The VOR time constant significantly decreased from 14.0±1.2s BA to 9.5±1.9s AA, while the PRV time constant was 13.1 ±2.1s BA and 11.1 ±2.0s AA. In contrast, the OKAN was enhanced by alcohol consumption. The area under the curve (AUC) of the OKAN showed an increase from 174.4 ±36.0° BA to 206.0 ±76.2° AA, while the AUC of the vection decreased from 19.8 ±27.4#round BA to 8.1 ±11.0#round AA.
Conclusions: Our results suggested that alcohol affects visuo-vestibular processing of self-motion signals by altering the cerebellar velocity storage mechanism. Similar patterns have been observed in patients with cerebellar degeneration, further suggesting that alcohol affects the vestibulo-cerebellar functionality altering self-motion perception. Support: SSA.
PP2-62 - Subjective cognitive dysfunction in patients with dizziness and vertigo
18. Spatial Orientation
Danica Xie1
Miriam Welgampola1, Laurie Miller2, Allison Young1,
Sally Rosengren
3
1 University of Sydney, Central Clinical School, Australia
2 Royal Prince Alfred Hospital, Institute of Clinical Neurosciences, Australia
3 Royal Prince Alfred Hospital, Neurology Department, Australia
Purpose: Patients with vestibular disorders sometimes report cognitive difficulties and there are documented effects of vestibular loss on cognitive functions such as visuospatial ability. Two studies recently found high levels of perceived cognitive difficulty in these patients, but there is no consensus about the cognitive functions affected. We therefore investigated subjective cognitive dysfunction in a broad range of neuro-otology patients and compared cognitive complaints to reports of emotional distress and functional disability.
Methods: We asked 131 neuro-otology clinic outpatients whether they experienced difficulties with thinking, memory or concentration as a result of dizziness. They (and 37 non-vertiginous control subjects) also completed four questionnaires: neuropsychological vertigo inventory (NVI), everyday memory questionnaire (EMQ), depression, anxiety and stress scales (DASS) and dizziness handicap inventory (DHI).
Results: Many patients (65%) reported experiencing cognitive difficulties. Compared to controls, patients scored significantly worse on five NVI subtests (assessing perceptions of space and time, attention, emotions and motor function, Ps<0.05), DASS (d=0.80, P<0.001) and DHI (d=2.1, P<<0.001), but not on the memory or vision NVI subtests or EMQ. Correlations between the NVI and DASS (r=0.57) as well as between the NVI and DHI (r=0.53) were significant (Ps<0.001). NVI space-perception subtest scores remained elevated after covarying DASS and DHI scores.
Conclusions: Patients with dizziness and vertigo reported high levels of subjective cognitive dysfunction, affecting spatial ability, orientation in time, and attention, but did not report significant memory difficulties. Perceptions of cognitive dysfunction covaried with emotional distress and functional disability. The most robust finding was subjective difficulty in navigation.
PP2-63 - Treatment of Mal de Debarquement Syndrome (MdDS) by readaptation of the vestibuloocular reflex (VOR)
18. Spatial Orientation
Sergei Yakushin
1
Mingjia Dai1
1 Icahn School of Medicine at Mount Sinai, Neurology Dept, USA
Purpose: MdDS is continuous sensation of motion which occurs after prolong travel (classic), or spontaneously. The common motion sensations (primary) are rocking, swaying. There are other accompanying (secondary) symptoms such as sensitivity to light, noise, head pressure, ear fullness, fussy vision, brain fog, anxiety, and depression, which are experienced by most patients.
Methods: Both the primary and secondary symptoms are varied in their presence among patients. Only rocking and swaying can be easily quantified. MdDS patients were treated by readaptation (Dai et al., 2014). Effectiveness of treatment was determined by patients’ self-assigned 10-point scale of overall symptoms.
Results: Before treatment, 431 patients (82% female, 350 classic, 81%) reported sensations of rocking (80%), swaying (73%), bobbing (43%), walking on trampoline (50%), and gravitational pull (64%). No primary symptoms were reported in 2% patients. Posturography determined significant rocking in 37% and swaying in 12% patients or both motions in 35% and 16% had only gravitational pull. Treatment was successful for 77% of patients with classic and 58% of patients with spontaneous MdDS. There was no correlation between improvement in postural stability and overall score. Treated patients also reported a reduction in secondary symptoms.
Conclusions: Thus, the lack of correlation between primary symptoms and overall score indicates that secondary symptoms are a very significant factor in treatment of MdDS. We demonstrated (Dai et al., 2017) that in some patients, symptoms returned in the first 2 weeks after treatment. Thus, control of secondary symptoms is a critical factor for the success of treatment by readaptation of VOR.
PP2-64 - Vestibular Function and Hippocampal Volume in the Baltimore Longitudinal Study of Aging
18. Spatial Orientation
Yuri Agrawal
1
Rebecca Kamil1, Tilak Ratnanather1, Athira Jacob1, Susan Resnick2
1 Johns Hopkins University
2 National Institute on Aging
Purpose: To evaluate whether reduced vestibular function in aging adults is associated with lower hippocampal volume.
Methods: This is a cross-sectional study using data from the Baltimore Longitudinal Study of Aging (BLSA), a long-running longitudinal cohort study of healthy aging. Participants were age ≥ 60 years and had both vestibular physiological testing and brain MRI at the same visit. Vestibular testing consisted of the cervical vestibular-evoked myogenic potential (cVEMP) to assess saccular function, ocular VEMP (oVEMP) to assess utricular function, and video head-impulse testing (VHIT) to assess the horizontal semicircular canal vestibulo-ocular reflex (VOR). The main outcome measure was hippocampal volume, calculated using diffeomorphometry.
Results: The study sample included 103 participants (range of 35-90 participants in sub-analyses) with mean (±SD) age 77.2 years (±8.71). Multivariate linear models including age, intracranial volume, sex, and race showed that 1μV amplitude increase of cVEMP was associated with an increase of 319.1 mm3 (p=0.003) in mean hippocampal volume. We did not observe a significant relationship between oVEMP amplitude or VOR gain and mean hippocampal volume.
Conclusions: Lower cVEMP amplitude (i.e. reduced saccular function) was significantly associated with lower mean hippocampal volume. This is in line with prior work demonstrating a link between saccular function and spatial cognition. Hippocampal atrophy may be a mechanism by which vestibular loss contributes to impaired spatial cognition in older adults. Future work using longitudinal data will be needed to evaluate the causal nature of the association between vestibular loss and hippocampal atrophy.
PP2-65 - Visual dependency in spatial orientation: The effect of body tilt and hemispheric lateralization
18. Spatial Orientation
Amir Kheradmand
1
Patricia Castro Abarca2, Shahvaiz Hussain3, Omer G Mohamed3, Adolfo M Bronstein2, Qadeer Arshad2
1 Johns Hopkins, Departments of Neurology and Otolaryngology & Head and Neck Surgery, USA
2 Imperial College London, Division of Brain Sciences, UK
3 Imperial College London, UK
Purpose: Perception of spatial orientation requires multisensory integration including visual, vestibular, and proprioceptive inputs. In this process, the degree of reliance on visual inputs is known as visual dependency. Here we used a Rod and Disc paradigm to measure visual dependency. In this paradigm, a full-field optokinetic stimulation (30°/s in clockwise and counter-clockwise directions) is used to induce tilt perception, which is measured by adjusting a visual line to upright orientation. We studied hemispheric lateralization using transcranial direct current stimulation (tDCS) over the left parietal region in comparison with a sham stimulation.
Methods: Visual dependency was measured in 24 participants (eight in each cathodal tDCS, anodal tDCS and sham stimulation groups) with 20 ° lateral head-on-body and whole-body tilts.
Results: Overall, visual dependency was biased towards the tilt direction when the head was tilted on the body, and was biased away from the tilt direction when the whole body was tilted. In the anodal group, compared with the cathodal and sham groups, the effect of body tilt on visual dependency was significantly biased toward the left side, and the effect of visually-induced roll tilt was significantly biased in the CCW direction.
Conclusions: These findings show that 1) visual dependency is affected by the relative head and body tilt positions, 2) the facilitatory -and not inhibitory- tDCS over the left hemisphere lead to a bias in visual dependency towards the side of stimulation, and 3) this bias is related to neural processing of both body tilt position and visual inputs.
PP2-66 - Visual gravitational motions affect estimation of subjective visual vertical (SVV)
18. Spatial Orientation
Vincenzo Maffei
1
Priscilla Balestrucci1, Alessandro Moscatelli1, Iole Indovina1, Francesco Lacquaniti2
1 Laboratory of Neuromotor Physiology, IRCCS Santa Lucia Foundation, Rome, Italy; Centre of Space BioMedicine, University of Rome Tor Vergata, Italy
2 Laboratory of Neuromotor Physiology, IRCCS Santa Lucia Foundation, Rome, Italy; Centre of Space BioMedicine and Department of Systems Medicine, University of Rome Tor Vergata, Italy
Purpose: Information on the orientation of gravity can be extracted both by static and moving visual clues. However, it is unknown whether the processing of static cues and that of dynamic cues are related. To clarify this point, we investigated whether gravitational motion might affect the perceptual judgment of SVV.
Methods: Twenty volunteers lying on the left side viewed a sphere on a screen moving under the simulated effect of gravity along a parabolic trajectory. They were instructed to intercept the sphere at the end of the trajectory. Trials were administered in blocks of 24. In each block the axis of the parabola was oriented either along the direction of Earth’s gravity (angle = 0°) or tilted relative to it (30°, 60° or 90°). To estimate the SVV, participants oriented vertically a luminous bar for 10 trials after each interception block.
Results: The estimation of SVV was affected by the tilt angle of the parabola seen in the previous interception block. In particular, the SVV errors were smaller in the early trials after the exposure to the parabolic trajectories aligned with Earth’s gravity. In the interception task, timing errors were reduced when the tilt angle of the parabola was closer to Earth’s gravity.
Conclusions: These data suggest that visual gravitational motions can contribute to estimating SVV. Moreover, the finding that the tilt angle modulated timing errors could reflect an internalized model able to predict the effect of gravity on moving objects.
PP2-67 - A diagnostic dilemma: beyond high resolution computed tomography (CT) scan, thinning versus fistula.
19. Superior Canal Dehiscence Syndrome
Kenneth Chua Wei De
1
Savitha Kamath1, Heng Wai Yuen1
1 Changi General Hospital, Department of Otolaryngology, Singapore
Purpose: We present two cases of computed tomography (CT) confirmed, Superior Semi-circular Canal Dehiscence (SSCD), with atypical Audiological findings. CT reformatted in the plane of Stenver and Poschl revealed a dehiscence on the left in the first patient and bilaterally in the second patient. However, the audio-vestibular test findings were not typical of SSCD.
Methods: Serial audiograms with immittance and acoustic reflexes were tested. Frenzel goggles was used to record eye movements for Tulios, Hennebert and Valsava signs. Vestibular evoked myogenic potential (VEMP) thresholds were sought and as the second patient was more symptomatic, she was referred for vestibular physiotherapy after a full vestibular assessment.
Results: Repeated audiograms showed no significant air-bone gaps in the SSCD ears. No nystagmus was recorded. VEMP threshold seeking was inconclusive in the first patient due to insufficient sternocleidomastoid muscle contractions and negative for the second patient on the left. The second patient also had confounding underlying vestibulopathy with absent right VEMP, reduced visual acuity, plantar flexors strength and standing balance.
Conclusions: Given the multiple clinical variations of SSCD, short of surgical confirmation, it was beyond the resolution of CT scans to discern between thinning and fistula. Here, we report unusual variants of sensorineural hearing loss that did not correlate with pure-tone audiometric air bone gaps as studies have suggested. VEMP thresholds for the diagnosis of SSCD may be challenging for older patients with poor muscle contractions. A full vestibular battery of tests should be performed to rule out underlying vestibular deficits that will confound the diagnosis of SSCD.
PP2-68 - Aggregating the symptoms of superior semicircular canal dehiscence syndrome
19. Superior Canal Dehiscence Syndrome
Vincent Van Rompaey
1
Laura Naert2, Paul Van de Heyning1, Bryan Ward3, Alexandre Bisdorff4, Jeffrey Sharon5, Raymond Van de Berg6
1 Antwerp University Hospital, Dept. Otolaryngology-Head & Neck Surgery, Belgium.
2 University of Antwerp, Faculty of Medicine and Health Sciences, Belgium
3 Johns Hopkins University School of Medicine, Dept. Otolaryngology-Head & Neck Surgery, USA.
4 Centre Hospitalier Emile Mayrisch, Dept. Neurology, Esch-Alzette, Luxemburg.
5 University of California, Dept. Otolaryngology-Head & Neck Surgery, San Francisco, USA.
6 Maastricht University Medical Center, Dept. Otolaryngology-Head & Neck Surgery, the Netherlands
Purpose: Superior canal dehiscence syndrome (SCDS) is caused by an absence of bone overlying the superior semicircular canal creating a third mobile window into the inner ear. When patients report their symptoms are causing significant impairments to their quality of life (QoL), surgeons have offered a variety of surgical procedures. Comparing the effectiveness of these procedures, however, is challenging, as there is no patient-reported outcome measure (PROM) designed specifically for evaluating SCDS-specific health-related QoL. The aim of this study was to perform a systematic review of all symptoms reported by patients with SCDS, with the goal of enabling the design of a condition-specific PROM.
Methods: Medline and PubMed databases were searched for articles that reported the preoperative symptoms of SCDS patients. Articles were excluded if they reported on associated diseases or did not report symptoms.
Results: Of the 397 articles retrieved, 66 were retained for quantitative analysis. Among 431 patients with SCDS, 1.253 symptoms were identified and 91 symptom terms were reported. After combining synonymous terms, 22 symptoms were derived by consensus. Of the raw total number of reported symptoms 92.5% can be attributed to 5 common symptoms: spontaneous dizziness (51%), autophony (42.5%), pressure-induced vertigo (37.4%), hearing loss (39.9%) and sound-induced vertigo (42.7%).
Conclusions: This systematic review of symptoms reported by SCDS patients identified a 22-item common symptom set. The 5 most frequently reported symptoms were spontaneous dizziness, sound-induced vertigo, autophony, hearing loss and pressure-induced vertigo. These items can be used towards creating a novel validated PROM in patients with SCDS.
PP2-69 - Correlation of neuroradiological and post-mortem autopsy findings in SCDS
19. Superior Canal Dehiscence Syndrome
Arne Ernst
1
Phillipp Mittmann*2
1 Dept. Otolaryngology at ukb, Hospital of the Univ of Berlin (Charité), Dept. Legal Medicine (Charité)*
2 Dept. Otolaryngology at ukb, Hospital of the Univ of Berlin (Charité)
Purpose: SCDS is a disorder which is – apart from the variable patient’s history - routinely diagnosed by audiological and neurotological testing and final confirmation by means of a HR-CT of the temporal bones. This is the routine diagnostic approach, but it has always been discussed inhowfar these findings reliably confirm the actual dehiscence.
Methods: In the present series, 22 suicide victims (44 temporal bones) were thoroughly investigated while undergoing an autopsy for medicolegal reasons (sucide by hanging – 17; by carbon monoxide intoxication – 3; by bleeding to death – 2). They were evenly distributed with respect to gender (age 23-75, 55.3 mean). Before the autopsy, the subjects were scanned with a HR-CT (1 mm slice thickness, 128 lines’ MS-CT, Brilliance, Philips Medical, Netherlands).
Results: In this series, the photographic documentation of the middle cranial fossa demonstrated a visibly open superior semicircular canal (SSC) in 3 subjects unilaterally and in one subject (bilaterally). The CT findings revealed an open SCC only in the one bilateral case which was confirmed by autopsy, but produced falsely positive results in five cases when the autopsy could not reveal any open SCC. In In essence, the correlations between the autopsy and the CT findings was positive in 75 % of the cases, but negative in 35 %.
Conclusions: This, in turn, indicated that the clinical decision making should primarily be based on the clinical findings and the major complaints of the patients, but only secondarily on the neuroradiological findings. As produced by HR-CT of the temporal bones with its possible technical artifacts.
PP2-70 - Fremitus Nystagmus - a simple and objective clinical sign for SCDS
19. Superior Canal Dehiscence Syndrome
Robert Gürkov
1
Claudia Jerin2, Wilhelm Flatz3, Rebecca Maxwell2
1 University of Munich, Otorhinolaryngology, Germany
2 University of Munich, Otorhinolaryngology & German Vertigo Centre, Germany
3 University of Munich, Radiology, Germany
Purpose: Superior Canal Dehiscence Syndrome (SCDS) is a great mimicker among the neurotological diagnoses. Its clinical manifestations and subjectively reported symptoms are variable and the response to surgical treatment is still not completely predictable. Diagnostic certainty is therefore of utmost importance. Here, we present a case series in which a simple diagnostic clinical sign emerged: Fremitus nystagmus.
Methods: Four patients with SCDS were included. The patients were examined with audiometry, head impulse test, caloric videonystagmography, cVEMP and oVEMP, high-resolution temporal bone CT. Eye movements were examined in response to Valsalva maneuvres and to the patients voice (humming). A video recording of eye movements is presented at the poster.
Results: All four patients had SCDS confirmed by temporal bone CT and VEMP. oVEMP had the highest diagnostic value of all functional test procedures, with an asymmetry ratio of more than 75% in all SCDS patients and a specificity of 100% among our general neurotologic patient population of more 1000 patients (cut-off at an amplitude of 30 uV). The audiometric air-bone gap was small (<10 dB). Valsalva maneuvres could only provoke a very faint – if any – nystagmus. In contrast, the vertical-torsional Fremitus Nystagmus, in response to the patient’s own voice, was clearly and easily observable under Frenzel goggles.
Conclusions: Fremitus Nystagmus is a clear and easy to perform objective clinical diagnostic sign for SCDS and more readily visible than nystagmus in response to Valsalva maneuvres. Physicians examining patients suspected of SCDS are encouraged to evaluate the presence of Fremitus Nystagmus.
PP2-71 - Hearing eyeball and/or eyelid movements on the side of a unilateral superior canal dehiscence
19. Superior Canal Dehiscence Syndrome
Pierre Bertholon
1
Pierre Reynard1, Yann Lelonge1, Roland Peyron1, François Vassal1, Alexandre Karkas1
1 Saint Etienne university hospital, France
Purpose: Hearing of eyeball movements has been reported in superior semicircular canal dehiscence (SSCD), but, not hearing of eyelid movements. Our main objective was to report the hearing of eyeball and/or eyelid movements in unilateral SSCD. Our secondary objective was to access its specificity to SSCD and discuss the underlying mechanism.
Methods: Six patients with SSCD who could hear their eyeball and/or eyelid movements were retrospectively reviewed. With the aim of comparisons, eight patients with an enlarged vestibular aqueduct (EVA) were questioned on their ability to hear their eyeball and/or eyelid movements.
Results: Three patients with SSCD could hear both their eyeball and eyelid movements as a soft low-pitch friction sound. Two patients with SSCD could hear only their eyelid movements, one of whom after the surgery of a chronic subdural hematoma. The latter remarked that every gently tapping on the skin covering the burr-hole was heard in his dehiscent ear as the sound produced when banging on a drum, in keeping with a direct transmission of the sound to the inner ear via the cerebrospinal fluid. One patient with SSCD, who could hear only his eyeball movements, had other disabling symptoms deserving operation through a middle fossa approach with an immediate relief of his symptoms. None of the eight patients with EVA could hear his/her eyeball or eyelid movements.
Conclusions: Hearing of eyeball and/or eyelid movements is highly suggestive of a SSCD and do not seem to occur in EVA. The underlying mechanism is discussed particularly the role of a cerebrospinal fluid transmission.
PP2-72 - Improving the Specificity of VEMP testing in Superior Canal Dehiscence: Trial by oVEMP
19. Superior Canal Dehiscence Syndrome
Rachael Taylor
1
Allison Young1, Emma Argaet2, Luke Fratturo2, Jacob Pogson1, Miriam Welgampola1
1 University of Sydney, Institute of Clinical Neurosciences, Australia
2 The Balance Clinic and Laboratory, Australia
Purpose: The recording of oVEMP amplitudes to air-conducted (AC) sound is a sensitive screening test for Superior Semicircular Canal Dehiscence (SCD). However, not all patients with large AC oVEMPs have SCD on CT imaging. This study sought to identify alternate diagnoses also producing large AC oVEMPs, and investigated outcome measures that would help differentiate between these cases and SCD.
Methods: In this study we reviewed the clinical records and BC oVEMP results of 42 clinic patients (53 ears) who underwent CT imaging due to enlarged AC oVEMP amplitudes. All patients were tested with BC oVEMPs to two different stimuli (1 ms square-wave pulse and 8 ms 125 Hz sine wave). Receiver Operating Characteristic (ROC) analysis was used to determine the diagnostic efficacy of BC oVEMP amplitude and latency outcome measures.
Results: Thirty-two ears were identified as having SCD; 21 had alternate diagnoses that included thinning of the bone covering (Near Dehiscence), Vestibular Migraine, Large Vestibular Aqueduct Syndrome and Ménière’s disease. BC oVEMP amplitudes to 1 ms pulses and 125 Hz sine waves were not helpful in discriminating between SCD and non-SCD patient ears (p>0.05). In contrast, oVEMP latencies to both BC stimuli were powerful discriminators (p<0.001). Sensitivity of the 125 Hz stimulus was higher than for the 1 ms pulse.
Conclusions: A two-step protocol that includes AC oVEMP amplitudes and low frequency (125 Hz) BC oVEMP latencies is recommended for optimizing the sensitivity and specificity of VEMP testing in SCD.
PP2-73 - Management of Dehiscences Involving Superior Canal and Tegmen
19. Superior Canal Dehiscence Syndrome
Martin Westhofen
1
1 RWTH Aachen University, ORL Department, Germany
Purpose: Superior semicircular canal syndrome can be complicated by tegmen dehiscence of the same ear. Diagnostic criteria and treatment are still in discussion.
Methods: A series of 10 patients (40-73 y, 4m, 6f) with ipsilateral SCDS and honeycomb tegmen were diagnosed and treated. 2 of them had residual complaints after occlusion in other centers. All had combined hearing loss, 5 had pathological middle ear compliance in addition to SCDS typical findings. Treatment was done via transtemporal approach with canal occlusion in 6 cases with open dehiscence and resurfacing of tegmen and canal with bioceramic (Bioverit) in all patients. 4 of the 10 patients had near dehiscence findings intraoperatively. Eustachian tube dysfunction in 6 patients was treated with ventilation tubes in addition to occlusion and resurfacing. Postoperative findings were compared with preoperative in all 10 cases.
Results: The air-bone gap was improved in 7 patients, bone conduction in 3 patients, VEMP thresholds were normalized in 8 cases, VEMP amplitudes and complaints (DHI) were improved in all patients. No correlation between radiologic size of dehiscences and pre-/postoperative findings was observed. The maximum of improvement in audiologic and neurotologic findings and complaints was observed in patients with preoperative Eustachian tube dysfunction in addition to the dehiscence findings.
Conclusions: Pathological pressure exposure of the superior semicircular canal can be increased by simultaneous pressure impact via middle ear and tegmen dehiscence. Therefore, the simultaneous investigation of SCDS, tegmen dehiscence and Eustachian tube dysfunction and the combined treatment in selected cases has to be considered.
PP2-74 - New issues within the third windows spectrum abnormalities impacting diagnosis and treatment
19. Superior Canal Dehiscence Syndrome
eugen ionescu
1
philippe guy2, pierre reynard1, lucian roiban3, Aicha Ltaief-Boudrigua4, francis Turjman5
1 Service d’Audiologie et Explorations Otoneurologiques, Groupement Hospitalier Est, CHU Lyon, France
2 Université Lyon, INSA-Lyon, Université Claude Bernard, CNRS UMR 5510, Laboratoire Vibrations Acoustiques, Bât. Blaise Pascal, 69621 Villeurbanne, France
3 Université Lyon, INSA-Lyon, Université Claude Bernard, CNRS UMR 5510, MATEIS, Bât. Blaise Pascal, 69621 Villeurbanne, France
4 Service d’Imagerie Médicale et Interventionnelle, Hospices Civils de Lyon, Centre Hospitalo-Universitaire Lyon, Lyon, France
5 Service d’Imagerie Médicale et Interventionnelle, Hospices Civils de Lyon, Centre Hospitalo-Universitaire Lyon, Lyon, France; Université Claude Bernard Lyon, CREATIS Unité CNRS UMR 5515 INSA Bat. 5
Purpose: In patients with superior semicircular canal dehiscence (SSCD), surface of bony defect correlates to the severity of symptoms. The objectives were to: (1) report a novel entity of the third windows spectrum; (2) present an innovative treatment for SSCD by the superior petrous sinus (SPS).
Methods: Two patients with particular forms of SSCD were retrospectively reviewed. The first showed brutal Tullio phenomenon (TP). The second complained of invalidating pulsatile tinnitus and dizziness aggravated by physical exercise.
Results: First patient showed moderate hearing loss without a conductive component in both ears. Tullio phenomenon (TP) was systematically observed when 2, 3 and 4 kHz pure tones were delivered at 110dB in the left ear. Tomodensitometry revealed a sub-millimeter dehiscence located on the ampullar region of the left superior semicircular canal. As the nystagmus was undoubtedly generated by an utriculofugal flow, it was hypothesized that mastoidien cells system acts as a Helmholtz resonator transferring acoustic energy directly to the vestibular end organ. In second patient, symptoms were caused by a SSCD in the right ear by SPS erosion. The treatment consisted in rigidifying the wall of the SPS (1.5 mm2 third window). Two stents were introduced by endo vascular approach in the SPS under general anesthesia. The patient reported immediate relief of his tinnitus, result still maintained three months after procedure.
Conclusions: (1) Limited ampullar dehiscence may explain some TP cases with “normal” petrous bone tomodensitometry. (2) In selected cases, endovascular treatment for SSCD by SPS is a safe and effective procedure.
PP2-75 - Ocular Vestibular Evoked Myogenic Potential Waveform Morphology: Signs of Superior Canal Dehiscence
19. Superior Canal Dehiscence Syndrome
Yvette Reid
1
Jane Lea2, Brian Westerberg2, Jolene Harrington1
1 Providence Health Care, Department of Audiology, Canada
2 University of British Columbia, Department of Surgery – Division of Otolaryngology Head And Neck Surgery, Canada
Purpose: To determine if the morphology of bone-conduction ocular vestibular evoked myogenic potentials (oVEMP) waveforms predicts the presence of superior canal dehiscence syndrome (SCDS) and if the characteristics of additional peaks predict the size and/or location of the dehiscence.
Methods: The charts of 38 patients (43 ears) with SCDS were reviewed, along with 43 age and gender matched controls. SCDS was diagnosed based on symptoms (sound and/or pressure related vertigo, autophony and/or conductive hyperacusis) and a positive CT or MRI scan. oVEMPs were evaluated for their asymmetry ratio (AR) and the amplitude of additional peaks between N1 and P1. The Additional Peak Amplitude Ratio (APAR) was calculated as the ratio of the largest additional peak amplitude to the N1 amplitude. Correlation co-efficients were used to identify the relationship between the amplitude of the peaks and the size/location of the dehiscence.
Results: 79% of the 43 SCDS ears but only one control had an APAR over 1%. The AR was highly specific (all 43 control subjects had an AR < 30%); however, the sensitivity was low (67%). When both measures were considered together the sensitivity and specificity were 95% and 98% respectively. There was no significant relationship between the size and location of the dehiscence on CT scans and the oVEMP measures.
Conclusions: Bone-conduction oVEMP morphology is a useful tool in diagnosing SCDS. oVEMP morphology markers are not dependent on the size or location of the dehiscence.
PP2-76 - Outcome of surgical plugging in superior canal dehiscence syndrome
19. Superior Canal Dehiscence Syndrome
Jae Joon Han1
Jae-Jin Song1,
Ja-Won Koo
1
1 Dizziness Center, Seoul National University Bundang Hospital, Korea
Purpose: Superior canal dehiscence (SCD) syndromes are characterized by tinnitus, noise- and pressure- induced vertigo, and autophony. Middle cranial fossa approach (MFA) is one of the surgery technique for SCD repair. In this study, we evaluate the outcome of MFA for SCD repair treatment.
Methods: Ten patients who underwent SCD repair via MFA were recruited. Median age of patients was 45 years (37-61) and median follow-up duration after surgery was 26.2 months (6-97.2). Clinical symptoms (autophony, aural fullness, hearing loss, imbalance, sound, pressure induced vertigo, and tinnitus), audiometry, vestibular evoked myogenic potential (VEMP), and electrocochleography(ECoG) were evaluated before and after surgery.
Results: Sensorineural hearing loss was developed after surgery in 1 patient. In the remaining 9 patients, preoperative bone conduction (BC) threshold (5.7±4.8 dB) increased after surgery (11.8±8.2 dB) (p=0.018). VEMP threshold was significantly improved after surgery (preoperative: 54.3 dB, postoperative: 82.3 dB, p=0.018). SP/AP ratio of ECoG was also significantly improved after surgery (preoperative: 0.51, postoperative: 0.30, p=0.028).
Conclusions: Most of subjective symptoms were relieved after SCD repair via MFA. Hypersensitive bone conduction threshold, air-bone gap, VEMP threshold and SP/AP ratio of ECoG were normalized after successful repair of SCD.
PP2-77 - Vestibular suppression of normal bodily sounds
19. Superior Canal Dehiscence Syndrome
Neil Longridge
1
Jim Renshaw2, Art Mallinson3, Anielle Lim4
1 University of British Columbia, Department of Surgery, Vancouver, CANADA
2 AIM Instrumentation; Vancouver, CANADA
3 University of British Columbia, Department of Surgery; Vancouver General Hospital, Vancouver, CANADA
4 St. Pauls Hospital, Audiovestibular Unit, Vancouver CANADA
Purpose: we propose that cochlear and vestibular efferents assist the stapedius reflex in suppressing ascending masking for bodily sounds, chewing and vocalizing. The human voice is extremely loud. Why do opera singers not have noise induced hearing loss. As vegetarian animals eat up to 80% of daylight hours, it is essential for them to hear predators approaching while chewing. The evolutionary advantage of this is clear. Despite chewing at a dinner party, hearing is relatively normal.
Methods: We measured the sound in the external auditory canal in response to chewing (celery, carrots) and also to singing loudly and demonstrated extremely loud sounds 30 cm in front of the mouth in the external auditory canal. We measured bone vibration to the head with resultant sound in the ear canal during chewing and singing.
Results: The stapedius reflex causes suppression of ascending masking of high frequency sounds by low frequency sounds.
Conclusions: There is equivocal evidence that cochlear efferents assist stapedius. Superior semicircular canal dehiscence is associated with autophony and dizziness during chewing because the compensatory process for internal sound is inadequate. It is hypothesized that the vestibular efferents suppress the sound stimulus from the external canal by air and vibratory responses by bone conduction, preventing these strong stimuli from inducing dizzy symptoms. The main purpose of the vestibular efferent system may be to suppress sound and vibration causing dizziness. Dizziness occurs in superior semicircular canal dehiscence syndrome because the stimulus is too great for intrinsic suppression mechanisms to be effective.
PP2-78 - VOG and VEMPs in Superior Semicircular Canal Dehiscence and Perilymfatic Fistula
19. Superior Canal Dehiscence Syndrome
Maja Striteska
1
Michal Janouch1, Jan Mejzlík1, Jakub Drsata1, Peter Sila1
1 Department of Otorhinolaryngology and Head and Neck Surgery , University Hospital Hradec Kralove
Purpose: The aim of the literature review and our cases report were to evaluate the best examination tool for diagnosing the perilymfatic fistula (PF) and superior semicircular canal dehiscence (SSCD).
Methods: Literature search, retrospective study of 11 cases with diagnosis of semicircular canal dehiscence and perilymfatic fistula, ocular and cervical vestibular evoked myogenic potentials (oVEMP, cVEMP), videonystagmography (VOG) and video head impulse test (VHIT).
Results: There are some differences in ”third window“ diagnoses. One of the main difference is integrity of the perilymfatic sac, next is a leak of perilymfatic fluid. In SSCD there is no hole in a perilymfatic sac, while in perilymfatic fistula is permanent or temporary hole, with an intermittent or continual leak of the perilymfatic fluid. In these diagnoses we can do nystagmus provocation tests on videonystagmography (Valsalva, exercising, loud sound, tympanometry), perform also VHITs. One of the most beneficial tests are VEMPs. SSCD has a lower threshold and larger amplitude of oVEMP and cVEMP anytime. According to location, oVEMP is more significant for SSCD. Contra to these findings, in perilymfatic fistulas, the VEMPs are fluctuating in results. Sometimes there are similar results to SSCD (lateral canal fistula in cholesteatoma), but sometimes we can also find normal or reduced VEMPs. We explain these fluctuating findings in perilymfatic fistulas due to fluctuant leak of perilymfatic fluid, which is not in SSCD.
Conclusions: Our experience corresponds with a literature search. Videonystagmography with VEMPs seem to be very good examination tools for to diagnose superior canal dehiscence and perilymfatic fistula for sure.
PP2-79 - Mild blast wave leads intensity-dependent sequential changes in MMP2 expression in rat brains
20. Traumatic Brain Injury
Takaki Inui
1
Carey Balaban2
1 Department of Otorhinolaryngology-Head and Neck Surgery, Osaka Medical College, Japan
2 Department of Otolaryngology, Neurobiology, Communication Sciences & Disorders and Bioengineering, University of Pittsburgh, PA, USA
Purpose: The prevalence of improvised explosive devices in warfare and terrorism has created unprecedented levels of blast-related traumatic brain injury (TBI). Mild TBI can sustain various symptoms, such as tinnitus, hearing loss, post-traumatic balance disorders, and migrainous disorders without overt histological and radiological findings. Matrix metalloproteinase 2 (MMP2) is a gelatinase with multiple functions at the neurovascular interface, including local modification of the glia limitations to facilitate access of immune cells into the brain amyloid-beta degradation during responses to injury or disease.
Methods: The present study examines regional changes in MMP2 immunoreactivity in the rat brain after a single mild (2.7-7.9 PSI peak) or moderate (13-17.5 PSI peak) blast overpressure (BOP) exposure through the expression isolated to patchy deposits in brain parenchyma surrounding blood vessels. MMP2 expression was examined quantitatively in histological sections of decalcified rat heads as a marker at 2, 24 and 72 hours after BOP exposure. Separate analyses were conducted for the cerebellum, brainstem and the cerebrum.
Results: The deposits varied in number, size, staining homogeneity (standard deviation of immunopositive region), and a cumulative measure, the product of size, average intensity and number, as a function of blast intensity and time. The sequences of changes in MMP2 deposits from sham control animals suggested that the mild BOP exposure differences was normalized within 72 hours in the subtentorial brainstem and cerebrum, but not the cerebellum.
Conclusions: Hence, local MMP2 responses may be a contextual biomarker for locally regulated responses to widely distributed brain injury foci.
PP2-80 - Temporal bone fracture in acute traumatic brain injury: Vestibular consequences
20. Traumatic Brain Injury
Heiko M. Rust
1
Brynmore Jones2, Mark Wilson2, Kevin Tsang3, Barry M. Seemungal1
1 Brain and Vestibular Group, Neuro-Otology Unit, Division of Brain Sciences, Charing Cross Hospital Campus, Imperial College London, Fulham Palace Road, London, W6 8RF
2 Department of Neuroradiology, St Mary’s Hospital, Imperial College Healthcare NHS Trust, W2 1NY
3 Department of Neurosurgery, St Mary’s Hospital, Imperial College Healthcare NHS Trust, W2 1NY.
Purpose: Traumatic brain injury (TBI) is the most common cause of death and disability in young adults with 1.4 million TBIs in the USA each year. Post-traumatic debilitating, long-lasting dizziness and chronic vestibular syndromes have been reported in up to half of patients in a 5-year follow-up study. Vestibular dysfunction and syndromes after TBI however have been recognised as an independent predictor of failure to return to work. Although many authors talk about acute injury to the vestibular apparatus and nerve, such reports are typically non-acute and retrospective.
Methods: As part of a routine clinical service at our Major Trauma Unit, we found that out of 49 TBI patients examined, 10 had clinical evidence of an acute peripheral unilateral vestibular injury (positive head-impulse-test and vestibular nystagmus). Cranial-CT scans depicted temporal bone fracture in 7 patients and no bone injury was apparent in 3.
Results: We report on a clinical follow up in 5 of these patients at least 2 years after acute TBI, 3 of whom having shown no temporal bone fracture on CT scan, clinical-neurologically, quantifying peripheral vestibular deficit using the video-head-impulse-test.
Conclusions: Possible causes inlcude a vestibular nerve transection, compression of the vestibular nerve by haematoma, or physical damage to the labyrinth. We present this, is to our knowledge, the first case series following acute peripheral vestibular loss in patients with acute TBI.
PP2-81 - The utility of the Sports Concussion Assessment Tool in hospitalized traumatic brain injury patients
20. Traumatic Brain Injury
Elena Calzolari
1
Matt Sargeant1, Emiko Sykes1, Mariyam Saviour1, Akshat Sawhney1, Joy Arthur1, Adrian McGoldrick2, Barry M. Seemungal1
1 Brain and Vestibular Group, Neuro-Otology Unit, Division of Brain Sciences, Imperial College London, Charing Cross Hospital, London W6 8RF, UK
2 The Turf Club, Kildare, Ireland
Purpose: The Sports Concussion Assessment Tool 3rd version (SCAT3) is a sports screening tool used to support return to play decisions following a head injury. The SCAT3 is presumed to identify brain dysfunction (implying a degree of brain injury), however the SCAT3 has never been validated with patients with definite acute traumatic brain injury.
Methods: 11 patients with Traumatic Brain Injury (TBI), abnormal acute neuroimaging, and over 18-years-old, were recruited from an acute major trauma centre, St Mary’s Hospital London. TBI patients and healthy controls were assessed with the SCAT3. This assessment tool includes a symptom evaluation and severity scale, a standardized cognitive assessment, and a clinical assessment of balance.
Results: We found that all three SCAT3 domains - symptoms, cognitive and balance assessments - TBI patients scored significantly worse than healthy controls. A correlation matrix (Bonferroni corrected) found no correlation between all subjective-objective SCAT3 assessment pairs (e.g. feeling unbalanced and balance examination). Removing Bonferroni correction revealed that the SCAT3 symptom of ‘pressure in the head’ had the largest number of co-correlations (including affective symptoms) overwhelmingly in a pattern indicating migraine.
Conclusions: The SCAT3 is sensitive in identifying patients with moderate-to-severe acute TBI compared to healthy controls. The lack of correspondence between objective and subjective assessments indicates an uncoupling of symptoms from signs – e.g. objective measures of imbalance may be a more reliable marker of brain injury than symptoms of feeling unbalanced. Subjective symptoms may additionally be modulated by non-brain injury mechanisms including migraine and psychosomatic inputs.
PP2-82 - Vestibular and optokinetic responses in post-concussive syndrome
20. Traumatic Brain Injury
Giovanni Bertolini1
Fausto Romano1, Dominik Straumann1, Nina Feddermann-Demont2
1 University of Zurich, Department of Neurology, Switzerland
2 Schulthess Clinic, Swiss Concussion Center, Switzerland
Purpose: Post-concussive syndrome (PCS) is a medical condition occurring in patients presenting a constellation of non-specific post-traumatic symptoms that persist beyond the expected time-frame for clinical recovery after a head trauma (i.e.10-14 days). Reports of dizziness and nausea are common in PCS and may have different origins. Often patients specifically report increased predisposition to visually-induced motion sickness. In this study, we focus on the central processing of visual and vestibular stimuli, evaluating whether rotatory chair testing can provide objective measures related to the reported symptoms.
Methods: Using a rotating chair surrounded by a horizontally rotating full-field optokinetic drum, 49 PCS patients were exposed to: angular velocity steps in darkness (60°/s for 90s) to quantify gain and time constant of the vestibulo-ocular reflex (VOR); sustained optokinetic stimulations (50°/s for 30s) to evaluate gain and time constant of the optokinetic afternystagmus (OKAN). Two repetitions of both tests were performed, changing the stimulus direction. Eye movements were recorded with video-oculography.
Results: OKAN time constants in PCS patients (median[MAD]: 16.7[5.1]s) were significantly larger (p<0.01) than in healthy subjects from published normative databases (10.5[2.5]s). No differences were observed for the other parameters.
Conclusions: An increase in the OKAN time constant is observed in PCS patients. The emerging evidence of a correlation between visual motion sensitivity and OKAN time constant in healthy subjects suggests a similarity between PCS and visual motion-sensitive individuals. Our findings, therefore, propose a novel way to objectify visual-induced motion sickness in PCS patients and support possible therapeutic approaches derived from motion sickness desensitization research.
Support:Schulthess Foundation.
PP2-83 - Why is routine vestibular screening not undertaken by trauma ward staff? A qualitative study
20. Traumatic Brain Injury
Rebecca Smith
1
Jonathan Marsden2, Caroline Burgess3, Barry Seemungal1
1 Imperial College London
2 University of Plymouth
3 Kings College London
Purpose: Vestibular disorders are a burdensome consequence of traumatic brain injury (TBI). There is growing data supporting the importance of routine vestibular screening, especially for common conditions such as benign paroxysmal positional vertigo (BPPV). However, a clinical audit completed at a major trauma centre (St Mary’s Hospital, London) demonstrated no formalised routine vestibular screening or assessment. We aimed to qualitatively explore the staff-related reasons for this.
Methods: This study employed a qualitative approach using semi structured interviews. The theoretical domains framework was used to ensure questions covered psychological and organisational theory relevant to behaviour change. Ward staff whose role include assessing patients with dizziness and/or imbalance (therapists, junior and senior doctors) were purposively sampled. Data was analysed using a Framework analysis approach.
Results: 12 ward staff participated (Mean age 31 years; 10 females). Interviews lasted on average 38 minutes. Data from interviews supported previous findings that no routine, formalised vestibular screening or assessment is undertaken in TBI patients. Prominent themes surrounding reasons for this lack of screening included insufficient skills and training, a responsibility gap between staff and low confidence in knowledge.
Conclusions: This study demonstrates a variety of knowledge and role-associated factors to be linked to a lack of routine vestibular screening following TBI. The clinical implications of this work are that patients with common vestibular conditions such as BPPV may be missed or poorly managed, leading to heightened and long-lasting physical, psychological and socioeconomic difficulties. Focused multidisciplinary theoretical and practical education is recommended.
PP2-84 - Acute dizziness/vertigo in the telestroke network TEMPiS: frequency and telemedical decision making
21. Vascular Vertigo
Peter Müller-Barna
1
Nikolai D. Hubert1, Nina Becker1, Holger A. Rambold2, Roman L. Haberl1, Gordian J. Hubert1
1 Staedtisches Klinikum Muenchen, Department of Neurology, TEMPiS Telemedical Stroke Center, Germany
2 County Hospitals of Altötting and Burghausen, Department of Neurology, Germany
Purpose: Acute dizziness/vertigo (AV) is a challenging symptom in the emergency department. Stroke has to be differentiated from peripheral vestibular and systemic disease. In telestroke the telemedical consultation determines the need for time critical stroke treatment. The aim of the study is to assess the frequency of AV in the teleconsultation service of a stroke network and the quality of its telemedical work up.
Methods: In the telestroke network TEMPiS two stroke centers provide care for 21 hospitals in rural Bavaria/Germany. Teleconsultants document the principal symptom of each consultation. In all cases of AV the teleconsultation report was reviewed and classified in predefined categories: peripheral cause: AV with contralesional horizontal nystagmus and ipsilesional positive head impulse test (HIT), without new focal neurological deficit (FND); central cause: new FND which also includes skew deviation and central nystagmus, or nystagmus and negative HIT; unclassified: all other cases.
Results: 407 (6.4%; of those 52.1% female, mean age 66.1 years) of 6.356 patients presented in our teleconsultation service in 2016 had the principal symptom AV. 10 cases (2.5%) met the classification criteria for a peripheral and 170 cases (41.8%) for a central cause, leaving 227 cases (55.8%) unclassified by the means of telemedicine. An informative HIT was available only in 37 cases (9.1%). 41 cases (10.0%) met the definition of acute vestibular syndrome.
Conclusions: AV is a frequent presentation in a stroke network, but the telemedical work up remains unsatisfactory as more than half remain unclassified. Measures to improve diagnostic quality are necessary.
PP2-85 - Canal and otolith test characteristics in vestibular neuritis and posterior circulation stroke
21. Vascular Vertigo
Zeljka Calic1
Andrew Bradshaw2, Leigh McGarvie2, Jacob Pogson2,
Allison Young2, Dennis Cordato1, Cecilia Cappelen-Smith1, Miriam Welgampola2
1 Department of Neurophysiology, Liverpool Hospital, NSW, Australia
2 Institute of Clinical Neurosciences, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
Purpose: Vestibular neuritis (VN) and posterior-circulation stroke (PCS) are the two most common causes of acute vestibular syndrome (AVS). Study aims to compare characteristics of semicircular-canal and otolith-function tests in PCS and VN
Methods: Cervical and ocular-vestibular evoked myogenic potentials (c-and oVEMP), subjective visual horizontal (SVH), and video-head impulse (v-HIT) tests were undertaken in 20 patients with acute VN and 16 with acute PCS. VEMP amplitude asymmetry-ratios (AR), ipsilesional horizontal v-HIT gains and catch-up saccade parameters were compared against healthy controls.
Results: The mean age was 55.5 for VN, 65.2 for PCS. Mean time to test was 5.7 days for VN, 8.1 days for stroke. Abnormality rates for AC cVEMP, BC oVEMP and SVH were 42%, 55% and 90% for VN, 46.7%, 6% and 71% for stroke.
For ipsilesional VN, PCS and healthy controls, horizontal v-HIT gains were 0.41, 0.89 and 0.96, cumulative amplitude was 3.44, 1.67 and 0.94, mean first saccade amplitude was 5.03°, 2.05° and 1.0° and first saccade onset latencies, 179.5ms, 277.6ms and 301.3ms. For VN, all four measures differed significantly from controls (p<0.05). In PCS patients, cumulative amplitude and first saccade amplitude were different (p<0.05).
Conclusions: A higher prevalence of oVEMP asymmetry, lower v-HIT gains and a higher cumulative amplitude of catch-up saccades help separate VN from PCS. Detailed saccade analysis is likely to complement existing vestibular tests.
PP2-86 - Diagnosing dizziness of vascular origin: are there safer options than arteriography?
21. Vascular Vertigo
Arlindo Cardoso Lima Neto
1
Edson Bor-Seng-Shu2, Marcelo de Lima Oliveira2, Alberto Macedo-Soares3, Flavia Renata Topciu4, Roseli Saraiva Moreira Bittar1
1 Department of Neurotology, School of Medicine, Universidade de São Paulo (USP), São Paulo, Brazil
2 Department of Neurology, School of Medicine, Universidade de São Paulo (USP), São Paulo, Brazil
3 Department of Geriatrics, Centro Universitário Lusíada (UNILUS), Santos, Brazil
4 Department of Geriatrics, Centro Universitário São Camilo, São Paulo, Brazil
Purpose: To evaluate the sensitivity and specificity of the magnetic resonance angiography (MRA) and transcranial Doppler ultrasound in the diagnosis of vertebrobasilar insufficiency (VBI).
Methods: We performed a cross-sectional study. We selected two groups: a control group (healthy subjects) and a group of patients who had clinical diagnosis of VBI. Each group included 12 patients, who were age- and sex-matched.
Results: The MRA results did not demonstrate significant differences in the findings of diseased and control groups. The transcranial Doppler demonstrated that the systolic pulse velocity of the right middle cerebral artery (sensitivity=0.83, specificity=0.75; p=0.028), final diastolic velocity of the basilar artery (sensitivity=0.66; specificity=0.66; p=0.028), pulsatility index (PI) of the left middle cerebral artery (sensitivity=0.83; specificity=0.75; p=0,005), PI of the right middle cerebral artery (sensitivity=0.75; specificity=0.75; p=0.010), and the PI of the basilar artery (sensitivity=0.91; specificity=0.91; p<0.001) were significantly higher in the diseased group compared to controls.
Conclusions: The MRA did not demonstrate significant changes in patients with VBI compared to controls. The PI of the basilar artery, measured using the transcranial Doppler, demonstrated high sensitivity (91%) and specificity (91%) levels in the diagnosis of VBI when the PI is higher than 1,01.
PP2-87 - Eye movements and vestibular function in patients with posterior circulation infarction
21. Vascular Vertigo
Yang Xu
1
Xia Ling1, Kangzhi Li1, Bo Shen1, Lihong Si1
1 Department of Neurology, Aerospace Center Hospital, Peking University Aerospace School of Clinical Medicine, Beijing,China.
Purpose: To evaluate the diagnostic values of eye movement and vestibular function tests in posterior circulation infarction (PCI).
Methods: 38 PCI patients and 34 patients with unilateral peripheral vestibular dysfunction (UPVD) were enrolled. All subjects were diagnosed with brain MRI and underwent eye movements and vestibular function tests, including spontaneous nystagmus (SN) and head-shaking nystagmus (HSN).
Results: The abnormal rate of eye movements was 78.9% in PCI group and 11.7% in UPVD group (P < 0.05). The positive rate of SN and HSN were 41.2% (7/17) and 43.8% (7/16) in cerebellar infarction patients, respectively, and the horizontal direction of SN and HSN coincided with the affected side in 85.7% (6/7) and 83.3% (5/6) patients, respectively. The positive rate of SN and HSN were 33.3% (2/6) and 66.7% (4/6) in medullary infarction patients, respectively, and the horizontal direction of SN coincided with the healthy side in 100% (2/2) and the horizontal direction of HSN coincided with the affected side in 75% (3/4) patients. The positive rate of SN and HSN were 20.6% (7/34) and 82.4% (28/34) in UPVD patients, respectively, and the horizontal direction of SN and HSN coincided with the healthy side in 100.0% (7/7) and 78.6% (22/28) patients, respectively.
Conclusions: Eye movement and vestibular function tests contribute to the early diagnosis of PCI. The horizontal direction of SN and HSN are consistent, toward the affected side in cerebellar infarction and the healthy side in UPVD. The horizontal directions of SN and HSN are contradictory in medullary infarction, which deserves further investigations.
PP2-88 - HINTS vs ABCD2 to predict cerebrovascular cause in acute vestibular syndrome patients at the ED
21. Vascular Vertigo
Anna Diamant
1
Jonatan Salzer1
1 Umeå University, Department of Pharmacology and Clinical Neuroscience, Sweden
Purpose: Posterior circulation stroke may be distinguished from peripheral vestibular disease among patients with acute vestibular syndrome (AVS) using the HINTS oculomotor examination battery (Head Impulse/Nystagmus/Test-of-skew). Previous studies are based on selected materials and/or lack quantitative vestibulo-ocular reflex (VOR) assessment. We sought to compare the accuracy of HINTS to a risk stratification tool (ABCD2) in an unselected population of AVS patients presenting to the ED using delayed magnetic resonance imaging (MRI) with diffusion weighted images (DWI) to define stroke.
Methods: Prospective two year study of AVS (defined as acute, persistent vertigo lasting > 24 h with nystagmus, and nausea/vomiting, head motion intolerance, or new gait unsteadiness) at a single academic center. All patients underwent admission, neurootologic examination, neuroimaging and follow-up. Eye movements were recorded by video-oculograpgy and quantative testing of the VOR by video HIT. The accuracy of HINTS was compared with ABCD2 risk scores to predict stroke using sensitivity, specificity and positive and negative likelihood ratios.
Results: Data collection runs until april 2018, and data processing has started. As of November 2017, n=175 patients had been included in the study, of which n= 21 (12%) had a cerebrovascular cause. We will further present the accuracy of HINTS in predicting cerebrovascular cause and compare this with ABCD2.
Conclusions: The patient management algorithm has performed well and data collection, including the video frenzel and vHIT systems, have worked well during the study period. Frequencies of cerebrovascular causes of AVS are as expected.
PP2-89 - Transient vertigo preceding vestibular neuritis
21. Vascular Vertigo
Richard Gerraty
1
Hayley Roberts2, Kunal Luthra2, Bernard Infeld3, Renee Bruce3
1 Monash University
2 Alfred Hospital
3 Epworth Hospital
Purpose: Transient vertigo may precede vestibular neuritis (VN), suggestive of TIA. We aimed to compare VN patients with and without transient premonitory vertigo to explore an age difference or VOR gain reduction difference between the two groups.
Methods: Consecutive patients with VN with onset in the previous 48 hours were enrolled. Following a detailed history and examination ICS Impulse video oculography (GN Otometrics) was performed.
Results: Amongst 32 patients with VN four had transient vertigo preceding. One man had two episodes lasting a few minutes in the preceding 30 days, and two more brief attacks on the day of presentation. Another had a single 30 minute episode four days before presentation. One had two attacks up to 10 seconds duration, one while riding a bicycle 4 days before VN. One woman had three brief attacks in the week prior to VN. The mean age was 49 (range 33-68), v mean age 63 (NS) for the remainder (range 33-88). None of the men had vascular risk factors. The mean VOR gain on the affected side was 0.52 v 0.65 (NS) in those without transient premonitory symptoms. All had normal brain MRI.
Conclusions: Transient premonitory vertigo may precede an attack of presumed VN by several days or more. More than one attack can occur. Transient premonitory vertigo may not be TIA, and may support a viral rather than a vascular mechanism for the acute vestibular syndrome. Greater numbers of patients will need to be recruited to explore this possibility further.
PP2-90 - A novel study on the relationship between dizziness or vertigo symptoms and nystagmus intensity
22. Vestibular and Inner Ear Physiology
wang wei
1
han xi1, chen taisheng1, xu kaixu1, Li Shanshan1, wen chao1, liu qiang1, lin peng1
1 Tianjin First Center Hospital First Center Affiliated Hospital of Nankai University, Otorhinolaryngology Head and Neck Surgery, China
Purpose: To explore the vestibule mechanism of dizziness and vertigo, defined and classified as the vestibule symptoms by ICVD.
Methods: 30 patients with peripheral vestibule disease accepted the caloric test, the change of the slow phase velocity (SPV) of nystagmus and recorded SPV threshold peak value induced dizziness or vertigo, and calculate the UW value were recorded. Comparing the SPV value of dizziness and vertigo occurred in patients under different conditions of caloric test (cold and hot air stimulation for each ear).
Results: The SPV values of patients with vertigo were higher than those of the dizziness. Among all the 30 patients, 19 had normal UW values and 11 cases were abnormal. There was no significant difference in the SPV peak value between the normal group and the abnormal group. There was no significant difference in the SPV value between the two groups when there was dizziness or vertigo.
Conclusions: Dizziness and vertigo have the same mechanism, which depend on the different intensity of vestibular stimulation.
PP2-91 - Efficiency of non-invasive cooling of the vestibular system
22. Vestibular and Inner Ear Physiology
Yening Feng MD1
C. Lane Anzalone MD1, David F. Kallmes MD2, Kent D. Carlson PhD3, M. Dan Dragomir Daescu PhD3, Shuai Leng PhD2, John I. Lane MD2, Gayla L. Poling PhD4, Neil T. Shephard PhD4, Devin L. McCaslin PhD4, Matthew L. Carlson MD1
1 Department of Otorhinolaryngolo, Mayo Clinic, Rochester, MN, USA
2 Department of Radiology, Mayo Clinic, Rochester, MN, USA
3 Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MN, USA
4 Division of Audiology, Mayo Clinic, Rochester, MN, USA
Purpose: To investigate the efficiency of non-invasive cooling of the vestibular system.
Methods: Two cadaveric temporal bones were implanted with thermocouplers at the external auditory canal (EAC), middle ear, lateral semicircular canal (LSCC) and cochlea. Good thermocoupler position was confirmed with thin-slice temporal bone CT. The temperature measurements were performed on each temporal bone when subjected to standardized temperature modulated irrigant instilled at the level of the EAC and middle ear, respectively. Air and water were used as irrigants.
Results: The temperature variation at the LSCC exhibited a linear change prior to reaching steady state. Both air and water irrigation succeeded in cooling of LSCC, with water irrigation resulting in a more efficacious temperature transfer. Direct water irrigation of the middle ear led to a more prominent temperature change compared with irrigation at the level of the EAC. Both air flow rate and input temperature showed positive correlation with degree of temperature change of the LSCC.
Conclusions: The results of this study demonstrate the efficiency of labyrinthine cooling with water or air irrigation of the external canal (EAC) or middle ear. Previous studies have demonstrated an anti-inflammatory effect of mild hypothermia after traumatic, toxic and ischemic organ injury. Future studies may evaluate for potential neuroprotective cooling in Meniere’s disease, labyrinthitis and other labyrinthine diseases.
PP2-92 - Impact of visual stimuli on cervical vestibular evoked myogenic potentials (cVEMPs)
22. Vestibular and Inner Ear Physiology
Emma Hesselstrand
1
Fatema Mohammed Ali1, Aaron Camp1
1 University of Sydney, Sydney Medical School, Australia
Purpose: cervical vestibular evoked myogenic potentials (cVEMPs) represent a measure of vestibulocollic reflex output, however little is known about how this reflex is modulated by other sensory inputs. Here we aimed to assess the impact of a simple, simultaneously presented visual stimulus on the Sternocleidomastoid (SCM) and Splenius Capitis (SPL) cVEMPs in healthy young individuals.
Methods: All procedures were done with approval from the University of Sydney Human Ethics committee. 23 healthy subjects were simultaneously exposed to a loud 4 ms, 500 Hz tone burst and one of five different visual motion conditions (vertical and horizontal drifting sinusoidal gratings; 4 cycles/degree spatial frequency. 1 cycle/degree temporal frequency). cVEMPs were measured from the SCM and SPL muscles using surface electromyography.
Results: cVEMPS were reliably recorded in both muscles during sound and visual stimulation. In general SPL cVEMPS across all conditions had shorter latencies to p13, with significant differences observed between SCM and SPL for vertical gratings drifting left and horizontal gratings drifting up (p < 0.05 for both). Similarly, SPL cVEMP amplitude was smaller for all visual motion conditions and reached significance for vertical gratings drifting left and horizontal gratings drifting down (p < 0.05 for both). Visual stimuli did not alter the incidence of cVEMPs with both muscles showing present cVEMPs in more than 80% of trials.
Conclusions: These data suggest that the addition of a visual stimuli does not alter the vestibulocollic reflex overtly. The subtle changes observed here may be further unmasked with more optimized visual stimuli.
PP2-93 - Is there any difference between clockwise and counter clockwise dynamic subjective visual vertical?
22. Vestibular and Inner Ear Physiology
Han Xi
1
Chen Taisheng1, Lin Peng1, Xu Kaixu1, Wang Wei1, Li Shanshan1, Wen Chao1, Liu Qiang1
1 Department of Otorhinolaryngology Head and Neck Surgery, Tianjin First Center Hospital,China. Otorhinolaryngology Institute of Tianjin,China.
Purpose: Analysis of dynamic unilateral centrifugation subjective visual vertical(SVV) deviations from normal young volunteers to understand the physiological characteristics of utricle.
Methods: In this study,39 young volunteers participated in SVV test and dynamic unilateral centrifugation SVV test with Neuro Kinetics Inc I-portal Video nystagmus recording system and NOTC rotating chair system.Rotate vertical axis at 300 deg/sec until horizontal canal VOR response subsides.Then linear translated to the right 3.85 cm.Then to center axis and then linier translated to the left 3.85 cm.Subjects stay at each position for 1 minutes and each one needs two dynamic SVV tests: counterclockwise rotation firstly and then clockwise rotation.The interval between the two rotation tests is 5 minutesWe record SVV data from three position and parameters such as mean value, standard deviation and so on will be calculated.
Results: There is no significant difference of SVV deviation between volunteers motionless and in the center position on rotating chair.In the process of counterclockwise rotation, there are statistical differences between the three positions in the left, middle and right positions of the SVV.The value is minimal at the right side, and the middle and left positions are increasing gradually.But in clockwise rotation, there is no statistical difference between the three positions.
Conclusions: The chair moves to the right, the right utricle respondsright utricle is stimulated by Gravity Inertial Acceleration (GIA) forces.When the chair moves to the left the left utricle responds.But this rule appears only during the first counter clockwise rotation.
PP2-94 - Pulsed infrared vestibular stimulation: evoked eye movement and cardiovascular responses
22. Vestibular and Inner Ear Physiology
Suhrud Rajguru
1
Gay Holstein2, Weitao Jiang3, Darrian Rice3, Giorgio Martinelli2
1 University of Miami, Biomedical Engineering and Otolaryngology, USA
2 Icahn School of Medicine at Mount Sinai, Neurology, USA
3 University of Miami, Biomedical Engineering, USA
Purpose: Over the last decade, a number of new techniques have been developed utilizing light to trigger neural activity that may overcome limitations of contemporary techniques used to probe and control neural function. With the present study, we demonstrate potential applications of pulsed infrared stimulation focused on the vestibular endorgans.
Methods: In a rat model, a surgical approach was developed to target pulsed infrared at individual semicircular canals and/or otolith organs. We measured evoked bilateral eye movements as a measure of activation of vestibulo-ocular reflex and changes in blood pressure and heart rate as a measure of activation of the vestibulo-sympathetic reflex pathways.
Results: The activation of vestibulo-ocular motor pathways by infrared stimulation targeted either at the vertical semicircular canals or utricular macula evoked significant, characteristic bilateral eye movements which remained consistent through several hours of repeated stimulation. These physiological responses could be maintained with 30+ minutes of continuous, frequency-modulated infrared stimulation. Simultaneously, we observed significant changes in blood pressure and heart rate with low frequency sinusoidal pulsed infrared activation of the posterior canal, whereas stimulation of utricular macula did not result in similar responses. The infrared activation of specific endorgans was reflected in the number and location of the central vestibular neurons and confirmed with micro-CT imaging of the inner ear.
Conclusions: Our results demonstrate a novel strategy for direct optical stimulation of the vestibular pathway in rodents and lays the groundwork for future applications of optical neural stimulation in inner ear research and therapeutic applications. Funding: R01 DC01379801, R01 DC008846.
PP2-95 - The Activity of Vestibular Pukinje Cells is Attenuated During Self-Generated Head Movements
22. Vestibular and Inner Ear Physiology
Omid Zobeiri
1
Kathleen Cullen2
1 Mcgill University, Montreal, Canada
2 Johns Hopkins University, Baltimore, USA
Purpose: The cerebellum, a structure that is well-conserved across vertebrates, has been suggested to drive sensory-prediction error-based motor learning. Neurons in the most medial of the deep cerebellar nuclei - the rostral fastigial nucleus (rFN) - are significantly more sensitivity to passively-applied compared to self-generated head movements. Further, during motor learning, the sensitivity of rFN neurons is modulated in a manner consistent with the computation of vestibular sensory prediction error. Here, to investigate the neuronal basis of these computations, we recorded from Purkinje cells, which project to the rFN neurons.
Methods: Single unit extracellular recording were made from Purkinje cells in the cerebellar cortex (Nodulus/Uvula) from rhesus monkeys, during active and passive head movements. Simple and complex spikes from Purkinje cells were detected via an automated clustering algorithm and sensitivity of each neuron to the head movement was computed using linear regression method.
Results: Analysis of neuronal responses during passive motion first revealed robust simple spike responses to head motion that were either bi or unidirectional. In comparison, simple spike responses during comparable active head motion were markedly attenuated. Moreover, analysis of the complex spike activity during passive and active head movement conditions showed the complex spikes are phase-locked with the onset of passive head movement, while fewer complex spikes were present during active head movements and phase locking was less evident.
Conclusions: Taken together, we conclude that the simple and complex spike responses of Purkinje cells are less robust during active than passive head movements.
PP2-96 - Case study: benefits of integrated vestibular rehabilitation in neurosarcoidosis
23. Vestibular Compensation and Rehabilitation
Igor Dijkers
1
1 Chiropractie Harderwijk, private practice, the Netherlands
Purpose: To describe quantitative and qualitative effects of vestibular, oculomotor and timing exercises in a 46-year-old female diagnosed with neurosarcoidosis. Initially, she was hospitalized with function loss including left-sided hemiparesis, facial and oculomotor paralysis. High dosages of prednisone quickly reversed these findings. Three months later she still suffered from inability to walk stairs unassisted, to balance on her left leg or to make quick turns while walking despite extensive physiotherapy.
Methods: Neurological evaluation demonstrated severe balance issues. Oculomotor evaluation (videonystagmography) demonstrated saccadic intrusions on smooth pursuit testing. Saccadometric evaluation demonstrated biphasic velocity curves. Timing and coordination capacity were severely reduced for the left lower extremity. Based on these findings a specific vestibular, oculomotor and timing training (Interactive Metronome) program was developed and administered in clinic and as home exercises.
Results: Saccadometric findings normalized completely. Timing and coordination errors reduced by 75 % for the left leg, and balance performance strongly improved. Within 4 sessions she was able to balance on a perturbed surface with her eyes closed and within two months of care she was able to walk the stairs unassisted and she returned to horseback riding and part-time work.
Conclusions: Residual brainstems symptoms post-neurosarcoidosis strongly improved after a specific training program implementing vestibular oculomotor and timing training and improved quality of living and ease of performing activities of daily living.
PP2-97 - Case study: Reduction of intercranial hypertension-induced vestibular symptoms
23. Vestibular Compensation and Rehabilitation
Igor Dijkers
1
1 Chiropractie Harderwijk, private practice, the Netherlands
Purpose: To describe the benefits of vestibular and sensorimotor rehabilitation for a 28-year-old female patient with idiopathic intracranial hypertension suffering from severe unsteadiness. She used acetazolamide to reduce the increased pressure. Even though pressure subsided to near normal levels her symptoms persisted, and she had to use a walker for walking and suffered from double vision and subjective sensory changes for five months.
Methods: Based on a comprehensive neurological evaluation a working hypothesis of diminished vestibular-proprioceptive-oculomotor integration with resulting coordination and timing issues and distorted awareness of body in space relationships was established. Vestibular findings were semi-circular canal specific in the LARP diagonal. A tailormade vestibular and sensorimotor rehabilitation program was implemented including gaze stability exercises, hemisphere specific saccade-pursuit training, vergence training en coordination and timing training using Interactive Metronome®.
Results: The patient was trained for 6 full days within a 10-day time frame and left the clinic being able to walk without assistance. She continued with home exercises for the next three months after which she was able to return to work, sports and driving.
Conclusions: Intracranial hypertension can give rise to vestibular and visual symptoms without explicit pathology. The dysfunctional integration of vestibular, visual and proprioceptive signalling can be addressed by reweighting and training of these three sensory systems and their central integration leading to resolution of symptoms.
PP2-98 - Case study: Resolution of centrally maintained vestibular symptoms secondary to BBPV
23. Vestibular Compensation and Rehabilitation
Igor Dijkers
1
1 Chiropractie Harderwijk, private practice, the Netherlands
Purpose: To describe the effects of vestibular rehabilitation exercises for resolution of BPPV symptoms unresponsive to Epley’s manoeuvres. This case study describes positive effects of vestibular rehabilitation strategies in a patient with persistent positional vertigo for 1 year.
Methods: Prior to presentation this patient was diagnosed with BPPV by his ENT specialist. Epley’s manoeuvre was performed and Dix Hallpike testing post repositioning was negative. However, symptoms did not resolve. Pathology was excluded based on CT-scan, bloodwork, CSF evaluation, ECG and urine testing.
Bedside vestibular and oculomotor evaluation were performed as well as a videonystagmography evaluation. Vestibular rehabilitation exercises to recalibrate and reweight vestibular input with proprioception and vision were provided both in clinic and as home exercises.
Results: Videonystagmography showed persistent left beating nystagmus in dark when head was in right posterior canal position. This is opposite to the nystagmus expected for right posterior canal positioning according to Ewald’s second law. Anterior and horizontal canal positioning did not result in nystagmus. This finding was interpreted as central compensation for initial peripheral vestibular pathology. After two sessions of vestibular and gaze stability exercises specific for the right posterior canal position symptoms resolved completely and videonystagmography findings were normal.
Conclusions: Positional vertigo in the direction of a specific semi-circular canal in which the direction of nystagmus is opposite to what is expected might be due to central vestibular compensation for initial BPPV. Targeted vestibular rehabilitation strategies might address this central compensation and provide a tool for recalibration of centrally maintained vestibular symptoms.
PP2-99 - Do sinusoidal gaze stabilising exercises result in adaptation of the transient (head impulse) VOR?
23. Vestibular Compensation and Rehabilitation
Carlo Rinaudo
1
Michael Schubert2, William Figtree1, Americo Migliaccio1
1 Neuroscience Research Australia, Balance and Vision Laboratory, Australia
2 Johns Hopkins University, Laboratory of Vestibular NeuroAdaptation, USA
Purpose: The vestibulo-ocular reflex (VOR) maintains stable vision during rapid transient head rotations. Vestibular rehabilitation includes active head rotation gaze stabilising exercises to improve postural control and possibly VOR adaptation. Currently, these consist of sinusoidal head rotations while looking at a space-fixed target. We sought to determine whether sinusoidal training leads to changes in the transient VOR.
Methods: We tested 6 normal subjects over 2 sessions. For protocol 1, subjects performed sinusoidal head rotations at 1.3 Hz while tracking a laser target whose velocity incrementally increased relative to head velocity so that the VOR gain (eye/head velocity) required to stabilise the target went from 1 to 2 over 15 minutes. For protocol 2, head rotation frequency incrementally increased from 0.5 to 2 Hz over 15 minutes, while the VOR gain required to stabilise the target was fixed at 2. We measured the active and passive, transient and sinusoidal (1.3Hz), VOR gains before and after each protocol.
Results: Sinusoidal and transient VOR gains increased due to the training, however, the sinusoidal gain increase was significantly larger (18.1%+/-2.3 vs 9.7%+/-1.4, P<0.0001). Protocol 1 training affected the active VOR more than the passive, whereas protocol 2 affected both (interaction, P < 0.03). The transient VOR increase was smaller than in studies where the training consisted of head impulses (16.2%+/-5.3) rather than sinusoidal rotations.
Conclusions: Sinusoidal adaptation training is not as optimal as head impulse training to increase the VOR during rapid head movements where its function is most important.
PP2-100 - Efficacy of vestibular rehabilitation exercises in acute unilateral peripheral vestibulopathy
23. Vestibular Compensation and Rehabilitation
Jae-Hyun Seo1
Eun-Ju Jeon1, Eun-Jin Son2, Dong-Hee Lee1, Jeong-Hoon Oh1
1 The Catholic University of Korea, College of Medicine, Department of ORL-HNS, Korea
2 Yonsei University College of Medicine, Department of Otorhinolaryngology, Korea
Purpose: The proper rehabilitation protocol for acute unilateral peripheral vestibulopathy (aUPV) has not been fully established to date. The objective of this study is to evaluate the effectiveness of 3 different vestibular rehabilitation exercises in patients with aUPV.
Methods: A prospective, randomized controlled study was conducted on 20 patients with vestibular neuritis and 3 patients of labyrinthitis. They were randomly assigned to a customized exercise (n=11), Cawthorn-Cooksey exercise (n=6) or simple VOR adaptation exercise (n=6) group. Balance performance and subjective disability were assessed with clinical and objective measurements before and after 4 weeks of training.
Results: Balance performance and subjective disability scores were significantly improved in all three exercise groups (p<0.05). However, there was no significant difference in the therapeutic effect among three exercise groups in terms of post-treatment values (p>0.05).
Conclusions: Customized and generic programs were equally effective in the improvement of dizziness and balance performance in short term follow up period in aUPV.
PP2-101 - HTC Vive to improve balance and dizziness in unilateral peripheral hypofunction: 2 case reports
23. Vestibular Compensation and Rehabilitation
Anat Lubetzky1
Bryan Hujsak2,
Jennifer Kelly
2
1 New York University, Department of Physical Therapy, USA
2 The New York Eye and Ear Infirmary of Mount Sinai, The Ear Institute, Hearing and Balance Center, Vestibular Rehabilitation
Purpose: Patients with vestibular dysfunction typically complain of dizziness and imbalance in busy and complex environments. We created a clinical app using the HTC Vive headset to provide a graded way for patients to experience these environments in a functional context and a safe manner. We describe the application of this novel intervention in 2 patients with unilateral peripheral vestibular hypofunction.
Methods: Within our app, patients explore a virtual street, airport or subway. The clinician controls direction, amount and speed of virtual people (5 levels each, starting empty). Two patients ages 72 and 75 performed 8 individualized sessions using the app, 5-7 scenes per session. Level of difficulty was gradually increased by: visual complexity, task duration (60-120 seconds) and movement (gait, head turns etc.). Progression was guided by symptoms.
Results: From baseline to post-intervention, Functional Gait Analysis improved from 20 to 26 (patient 1) and 17 to 20 (patient 2). Four Step Square Test has not changed for patient 1 (9 seconds) but improved from 15 to 8 seconds in patient 2. Both patients improved their Activities-Specific Balance Confidence (52% to 70% and 41% to 59%); their Visual Vertigo Analog Scale (284mm to 211mm and 640mm to 234mm) and their State (S) / Trait (T) Anxiety (from 46(S)/37(T) to 22(S)/27(T) and from 32(S)/25(T) to 21(S)/21(T)).
Conclusions: Our Vive app enables patients to engage in safe yet challenging environments that are not easily reproducible in traditional rehabilitation. Using this platform could improve balance and reduce anxiety in patients with vestibular hypofunction, especially in busy environments.
PP2-102 - Impact of Vestibular Rehabilitation on Patients with Chronic Vestibular Hypofunction
23. Vestibular Compensation and Rehabilitation
Anamarija Sestak1
Sinisa Maslovara
2
1 Department of Otolaryngology, County General and Veterans Hospital Vukovar, Zupanijska 35, Vukovar, Croatia
2 Department of Otorhinolaryngology and Maxillofacial Surgery, Medical Faculty, University of Osijek, J. Huttlera 4, Osijek 31 000, Croatia
Purpose: The goal of the study was to show the impact of vestibular rehabilitation in patients with chronic unilateral vestibular hypofunction (CUVH) and bilateral vestibular hypofunction (BVH) on reducing the symptoms and reducing the risk of falling.
Methods: In this study, we analysed the data of 30 patients with CUVH and 20 with BVH treated with vestibular rehabilitation. Inclusion criteria were as follows: symptoms persisting more than three months, the bi-caloric tests results showing the uncompensated weakness of one or both labyrinths, with Dizziness Handicap Inventory (DHI) ≥40 and the Activities-specific Balance Confidence (ABC) Scale ≤66%. Adaptational, substitutional and habituation exercises were customised to CUVH patients, while BVH patients performed substitution and adaptation exercises.
Results: In both groups of patients, there was significantly less disablement as a result of the disease between the initial and final DHI scores (from 59-20 in CUVH and 74-41 in BVH group). There was a significant increase in the balance confidence between the initial and final ABC Scale in both groups of patients (from 49,5-90% in CUVH and 42-73% in BVH group).
Conclusions: Both patient groups demonstrated a significantly better result in the DHI and ABC scores after vestibular rehabilitation. The results of ABC were inferior, and the treatment duration was longer in the BVH group. According to the state of impairment, disability and functional performance, physiotherapist performed carefully selected and individually tailored exercises. Responsible implementation of vestibular rehabilitation can lead to significant results in the treatment of patients with CUVH and BVH.
PP2-103 - Is Static Acuity Pre-requisite for Dynamic Visual Acuity: Case Series Failed Vestibular Rehab
23. Vestibular Compensation and Rehabilitation
Janet Helminski
1
Melissa Suckow2
1 Midwestern University, Physical Therapy, USA
2 Midwestern University, Optometry, USA
Purpose: To describe the impact of unrecognized pre-existing ocular misalignment of 3 patients with acquired unilateral peripheral vestibular deficits who underwent a course of vestibular rehabilitation resulting in partial resolution of oscillopsia.
Methods: A retrospective case series of 3 patients diagnosed with unilateral peripheral vestibular hypofunction or post-concussion dizziness, who were unsuccessfully treated with gaze stability exercises, and then referred to out patient vestibular rehabilitation clinic. Two complained of a pre-existing vertical diplopia, 1 gaze right and the other with gaze up and towards left. The cover-uncover test was performed in the 9 diagnostic positions of gaze with neutralization of deviation with prism bars. The Park’s 3 step test was performed to identify isolated cranial nerve palsies. All received vision therapy prior to 2nd episode of vestibular rehabilitation.
Results: All patients had a pre-existing tropia or phoria. Neutralization of deviation in 1 patient in the gaze right position was 8 diopter base up and the other patient in the gaze up and left position was 8 diopters base up. The third patient had an 12 diopter right exophoria. Following vision therapy and vestibular rehabilitation, all were able to maintain a stable gaze at minimal to moderate frequencies of head movements. None were able to maintain a stable gaze at high frequency.
Conclusions: Pre-existing ocular misalignment may be associated with failure to compensate for a new vestibular hypofunction. Static visual acuity should be optimized prior to gaze stability exercises.
PP2-104 - Manifestation and Prognostic Factors of Dizziness due to Long-Term Use of Vestibular Suppressant
23. Vestibular Compensation and Rehabilitation
Myung-Whan Suh
1
Younghoon Cho1
1 Department of Otorhinolaryngology-Head and Neck Surgery, Seoul National University Hospital
Purpose: The objective of this study was to investigate the clinical manifestation and prognostic factors of long term use of vestibular suppressants which elicit various atypical vestibular symptoms.
Methods: Serial follow up of 32 patients who were diagnosed as vestibular suppressant drug associated dizziness (DAD) was performed. The numeric rating scale (NRS) on dizziness symptom, vestibular function test outcome, compliance to treatment, and prognosis were evaluated. The duration of illness was 44.4 ± 47.3 months and the duration of vestibular suppressant drug intake was 20.0 ± 20.9 months. The prognosis was categorized as good (improvement in NRS≥50%) or unsatisfactory (improvement in NRS<50%).
Results: Most of the patients (65.6%) complained of spinning vertigo . The severity of the DAD symptom was dependent on the preceding vestibular disorder: it was most severe when the preceding vestibular disorder was vestibular neuritis. Unilateral vestibulopathy was identified in 42.9-52.0%, regardless of which vestibular function test was performed. Atypical vestibular function test findings that cannot be fully explained by known vestibular disorders were frequently found: direction changing positional nystagmus (25.0%), direction changing VIN (9.4%), and HIT corrective saccades that did not correlate with caloric test (22.2-42.9%). Old age, non-compliance to VRT, and vestibular neuritis as the preceding vestibular disorder were bad prognostic factors.
Conclusions: Frequent atypical vestibular function test findings in DAD should not be confused for central signs. Vestibular neuritis as the preceding cause of DAD and old age may hamper the recovery, due to combined peripheral and central deficit. But active vestibular rehabilitation may be an effective solution.
PP2-105 - Noisy galvanic stimulation improves vestibular perception
23. Vestibular Compensation and Rehabilitation
Klaus Jahn
1
Aram Keywan2, Max Wuehr2
1 University of Munich LMU and Schoen Clinic
2 University of Munich LMU
Purpose: Noise can enhance information processing in sensory systems via stochastic resonance. It has recently been demonstrated that noisy galvanic vestibular stimulation (nGVS) improves balance control in healthy subjects and in patients with bilateral vestibular hypofunction, both during standing and during walking. It affects vestibulospinal reflex thresholds. It is not known whether there is a simultaneous enhancement of vestibular perception.
Methods: Fifteen healthy subjects (mean age 25.1±1.7 years) performed quiet-stance tasks on foam with eyes closed at eight different nGVS amplitudes ranging from 0 mA (baseline) to 0.5 mA. The nGVS amplitude that improved balance performance most compared to baseline was assigned as the optimal nGVS amplitude. The effect of nGVS delivered at the determined optimal intensity on perception was examined using direction-recognition tasks on a motion-platform, testing roll rotations and translations at 0.2, 0.5 and 1.0Hz.
Results: nGVS significantly reduced direction recognition thresholds compared to the sham condition at 0.5Hz (ANOVA p=0.045; F= 5.006; mean threshold reduction: 14.1±0.5 %) and 1.0Hz (ANOVA p=0.013; F=8.455; mean threshold reduction: 20.1±0.5 %). No correlation was found between nGVS-induced improvements in balance control and vestibular motion perception at 0.5 and 1Hz, which may suggest different mechanisms by which nGVS affects both modalities.
Conclusions: We show that nGVS can enhance vestibular motion perception. The outcomes of this study are likely to be relevant for the potential therapeutic use of nGVS in patients with balance problems.
PP2-106 - Pediatric vestibular rehabilitation: A case study
23. Vestibular Compensation and Rehabilitation
CAMILLA CAVASSIN ALVES
1
ANDRÉ LUIS SANTOS SILVA1
1 Instituto Brasileiro de Fisioterapia Vestibular (IBRAFIVE)
Purpose: A nine-year-old child with a 9-month history of complaints of dizziness, headache, and motion sensitivity presented to physical therapy. The patient complained of difficulties playing on a playground, running, being a passenger in a car, watching “action movies”, sitting under fluorescent lights, and making quick head movements.
Methods: An initial evaluation consisting of a clinical oculomotor exam, vergence testing, static and dynamic visual acuity testing, head impulse testing, subjective visual vertical, balance testing, functional reach, the pediatric vestibular symptom questionnaire (PVSQ), the Dizziness Handicap Inventory- patient caregivers version (DHI-PC) and a visual vertigo analog scale (VVAS). The use of virtual reality with x-box games, adaptation, habituation and balance exercises were prescribed. She was seen once/week and was told to perform her exercises 2-3 time a day.
Results: After 10 sessions (approximately 11 weeks) she reported that playing was easier, headaches had reduced, she could travel as a passenger in a car in long distances without complaints and that she could watch 3-D action movies without symptoms. Her PVSQ scores had reduced from 0.7 to 0.1 and her VVAS scores were improved. The DHI-PC has decreased from 22 to 12 points .
Conclusions: Vestibular rehabilitation improved this child’s quality of the life. She was able to return to her daily living activities with less symptoms.
PP2-107 - Prognosis after Acute Unilateral Vestibulopathy: the importance of video Head Impulse Test.
23. Vestibular Compensation and Rehabilitation
Augusto Pietro Casani
1
Niccolò Cerchiai1, Elena Navari1, Chiara Re1
1 Pisa University Hospital, Italy
Purpose: To describe the relationships among the main instrumental features characterizing an acute unilateral vesti- bulopathy and to clarify the role of the video head impulse test in predicting the development of chronic vestib- ular insufficiency.
Methods: Sixty patients suffering from acute unilateral vestibulopathy were retrospectively analyzed: 30 who recovered spontaneously (group 1) and 30 who needed a vestibular rehabilitation program (group 2). The main out- come measures included Dizziness Handicap Inventory score, canal paresis, high-velocity vestibulo-oculomotor reflex gain, and catch-up saccade parameters. The tests were all performed between 4 and 8 weeks from the onset of symptoms.
Results: The high-velocity vestibulo-oculomotor reflex gain correlated with the Dizziness Handicap Inventory score (P = .004), with the amplitude of covert and overt saccades (P \ .001), and with the prevalence of overt saccades (P \ .001). Patients in need for vestibular rehabilitation programs had a significantly lower gain (P \ .001) and a higher preva- lence and amplitude of overt saccades (P = .002 and P = .008, respectively). Conversely, we found no differences in terms of response to the caloric test (P = .359).
Conclusions: Lower values of high-velocity vestibulo-oculo- motor reflex gain and a high prevalence of overt saccades are related to a worse prognosis after acute unilateral vesti- bulopathy. This is of great interest to clinicians in identifying which patients are less likely to recover and more likely to need a vestibular rehabilitation program.
PP2-108 - Smartphone-based Virtual Reality Vestibular Therapy App for Motion Sickness
23. Vestibular Compensation and Rehabilitation
Caroline Schlocker
1
Samuel Frasier1
1 Naval Medical Center Portsmouth, VA, USA
Purpose: Demonstrate the clinical effectiveness of virtual reality (VR) vestibular therapy delivered via a portable VR smartphone-based application (app) for motion sickness.
Methods: Four subjects who suffered from motion sickness were enrolled in a pilot study of the researcher-developed VR smartphone-based app. Subjects were asked to complete thirty VR vestibular therapy sessions over a six week time period. The primary outcome measure was a change in the Dizziness Handicap Index (DHI) score to determine the improvement in motion sickness symptoms. Vestibular therapy compliance data was automatically recorded via a backend SQL database.
Results: Three of the four subjects had a >15 point DHI score reduction (19-28), indicating a clinically significant improvement. One subject had a 12 point improvement in DHI. The database-generated compliance data were examined. Three of the four subjects participated in fewer sessions than originally directed (10-32). The subject who did not show a clinically significant change in DHI completed the fewest number of sessions (10).
Conclusions: VR vestibular therapy via smartphone-based app resulted in DHI score improvement for all users. There was poor compliance with the recommended number of sessions. The portable smartphone-based app has exciting potential for cost-effective therapies that can be widely distributed. The automatic data collection facilitates analysis for research and therapeutic purposes.
PP2-109 - Subsensory Neuromodulation Improves Vestibular Function in Bilateral or Unilateral Hypofunction
23. Vestibular Compensation and Rehabilitation
Jorge Serrador
1
Yoav Gimmon2, Scott Wood3, Michael Schubert2
1 Rutgers Biomedical Health Sciences
2 Johns Hopkins University
3 Azusa Pacific University
Purpose: Loss of vestibular function can be debilitating and greatly affect quality of life. Our group has been developing a novel subsensory neuromodulation device to enhance vestibular function and balance. The goal of the current work was to determine if this stimulus would be effective in patients with either bilateral or unilateral vestibular hypofunction.
Methods: We measured static sway while standing on a force plate for 30 sec trials, either with eyes open or closed. During the trials we provided low levels of random bilateral electrical current to the ear lobes (mean 0 with SD<0.2 mA) to enhance vestibular function based on the principle of stochastic resonance. Three trials of sham and stim in each condition were performed. Patients were unable to feel the stimulus.
Results: While all patients were able to maintain balance well with eyes open on firm surface, upon closing their eyes there was a significant increase in sway in the bilateral (+1326%) and the two unilateral patients (+560% & +56%), as was expected since the patients have no or reduced vestibular inputs and therefore must rely on visual inputs. During stim trials the sway area reduced in all the patients with the greatest reduction in the bilateral (-53%) compared to the unilateral patients (-29% & -8%).
Conclusions: The decrease in sway in all the patients during the eyes closed trial indicates that the device was effective in enhancing balance, presumably through vestibular mechanisms. This initial work supports the concept of using neuromodulation as a treatment for vestibular loss.
PP2-110 - The effect of consolidation on human vestibulo-ocular reflex adaptation and retention.
23. Vestibular Compensation and Rehabilitation
Muntaseer Mahfuz
1
Michael Schubert2, William Figtree1, Christopher Todd1, Serajul Khan1, Americo Migliaccio1
1 Balance and Vision Laboratory, Neuroscience Research Australia
2 Laboratory of Vestibular NeuroAdaptation, Otolaryngology-HNS, Johns Hopkins University
Purpose: The vestibulo-ocular reflex (VOR) is the main gaze stabilising system during rapid head movements. The VOR is highly plastic and its gain (eye / head velocity) can be increased via training that induces an incrementally increasing retinal image slip error signal to drive VOR adaptation. The unilateral incremental adaptation technique typically consists of one 15 minute training block. We sought to determine if separating the training into 3x5 minute blocks with 20 minutes in between, as generally recommended for other vestibular exercises, would result in consolidation leading to improved VOR adaptation and retention.
Methods: We tested 11 normal subjects, each over 6 separate sessions/days. We tested three different 5 minute training protocols. For each training protocol, we measured the active and passive VOR gains before and after: 3x5 minute training with 20 minute consolidation breaks, and 5 minutes of training only. For training with consolidation breaks, we measured retention of the VOR gain over one hour and compared results to a prior retention study.
Results: VOR gain adaptation with 1x5 minutes training was approximately one third of that observed after 3x5 minutes training, suggesting that consolidation does not affect VOR gain adaptation, i.e., there was no synergistic affect. Retention was also unaffected by the addition of the consolidation break between exercises.
Conclusions: These data have implications for vestibular rehabilitation, suggesting that optimal VOR adaptation exercises can be performed in one continuous or separated in time blocks.
PP2-111 - The role of physiotherapy in managing vestibular migraine: A critical literature review
23. Vestibular Compensation and Rehabilitation
Ryan Fraser
1
1 The Vestibular Rehab Clinic
Purpose: Is there research supporting the use of physiotherapy in managing individuals with vestibular migraine?
Methods: A literature review of published papers in EMBASE, PEDro and Cochrane Databases between 1990 and 2017. Quality of the identified papers was assessed using the Jadad scale and PEDro scale. The studies utilised a range of heterogeneous outcome measures such as balance, gait, visual analogue scale (VAS) for pain intensity and the Dizziness Handicap Inventory.
Results: The search yielded four studies of poor quality and two case studies. Studies consisted of research evaluating the benefits of vestibular rehabilitation therapy in individuals with vestibular migraine and migrainous associated vertigo. Therapy typically consisted of gaze stability, habituation, balance and gait exercise programs delivered by a physical therapist. These treatment programs were found to be safe and moderately effective in managing vestibular migraine associated impairments such as dizziness, balance and gait disturbances. There was insufficient evidence to suggest any benefit of treatment on migraine pain intensity. Manual therapy to the cervical spine was recommended if there was any concurrent neck pain identified, however there was no quantitative data to support this.
Conclusions: From the limited number of high quality studies conducted, this review supports the existing body of evidence that vestibular rehabilitation delivered by a physiotherapist maybe an efficacious modality in managing the associated impairments of vestibular migraine. However, studies have not investigated if these interventions can reduce the frequency or severity of migrainous episodes or if manual therapy to the cervical spine may improve outcomes.
PP2-112 - Therapy of impaired upright body orientation using a 3D device
23. Vestibular Compensation and Rehabilitation
Klaus Jahn
1
Susanne Tillmann2, Carmen Krewer2, Friedemann Müller2, Jeannine Bergmann1
1 Schoen Clinic Bad Aibling and University of Munich LMU
2 Schoen Clinic Bad Aibling
Purpose: Pusher behavior is a disorder of verticality perception and impairs postural control. Patients actively shift their center of gravity towards the paretic body side and resist passive correction. They orient the body toward a disturbed inner reference of verticality. Pusher behavior hampers the rehabilitation process and prolongs hospitalization. The aim of this pilot study was to investigate the effectiveness of verticality training with the Spacecurl device on pusher behavior and standing balance.
Methods: Stroke patients with pusher behavior were included (Burke Lateropulsion Scale = BLS ≥3). Patients trained three times within one week on the Spacecurl (each session 30 minutes). Before and after the intervention the BLS and the Subjective Postural Vertical (SPV) were tested.
Results: Four patients (median BLS 5, range 3-8) were included. All patients improved pusher behavior after intervention (mean BLS pre 6.5, post 4.5). In one patient pusher behavior ceased (BLS <3). At pretest, all patients showed an altered SPV in both the roll and the pitch plane. The SPV in roll was on average 2.1° tilted to the ipsilesional side. This deviation normalized after the intervention phase (mean 0.1°). Further, the baseline SPV was tilted backwards (mean -3.4°) and slightly improved after the interventions (mean -2.9°).
Conclusions: Therapy with the Spacecurl improves pusher behavior. The device provides a unique opportunity to experience the tilted body position in space without the risk to fall. Visual feedback can be used to correct a mismatch between perceived and actual body position. This is a promising approach for treatment of severe postural imbalance.
PP2-113 - Training time affects human vestibulo-ocular reflex adaptation.
23. Vestibular Compensation and Rehabilitation
Muntaseer Mahfuz1
Michael Schubert2, William Figtree1, Christopher Todd1, Serajul Khan1,
Americo Migliaccio
1
1 Neuroscience Research Australia, Balance and Vision Laboratory, Australia
2 Johns Hopkins University, Laboratory of Vestibular NeuroAdaptation, USA
Purpose: The vestibulo-ocular reflex (VOR) is the main gaze stabilising system during rapid head movements. The VOR is highly plastic and its gain (eye / head velocity) can be increased via training that induces an incrementally increasing retinal image slip error signal to drive VOR adaptation. Using the unilateral incremental VOR adaptation technique and horizontal active head impulses as the vestibular stimulus, we sought to determine the factors important for VOR adaptation including: the total training time, ratio and number of head impulses to each side (adapting and non-adapting sides; the adapting side was pseudo-randomized to be left or right) and exposure time to the visual target during each head impulse.
Methods: We tested 11 normal subjects, each over 5 separate sessions and training protocols. Each protocol consisted of up to 15 minutes of unilateral incremental VOR adaptation training. The training protocols were designed so that the effect of each training factor on adaptation could be determined. The active and passive VOR gains were measured before and after training.
Results: Our data suggest that the total training time (5.7%+/-3.8 vs 9.0%+/-4.5, P<0.05) and the visual target exposure time for each head impulse (16.2%+/-5.3, P<0.005) affected adaptation, whereas the total number and repetition rate of head impulses did not.
Conclusions: These data have implications for vestibular rehabilitation, suggesting that quality, i.e. eyes open throughout each head rotation with concentrated training towards the side with vestibular hypofunction, and duration of VOR adaptation exercises are more important than rapid repetition of exercises.
PP2-114 - Changes CGRP serological parameters in patients with vestibular migraine
24. Vestibular Migraine
Liu Xin Yi
1
1 Harbin Medical University,harbin,China
Purpose: Previous studies have shown that CGRP is associated with migraine. However, the relationship between CGRP and vestibular migraines remains unclear. Nearly zero detail studies of vestibular migraine with the patient’s gender, age, hormone level, and cognitive decline are relevant. The purpose of this observational cohort study was to determine if serum CGRP could be a serological marker for patients with vestibular migraine.
Methods: The study was conducted from July 2017 to December 2017. Thirty cases of migraine headaches and 30 healthy controls in the First Affiliated Hospital of Harbin Medical University were selected as the study subjects. CGRP was measured by immunoturbidimetry. The severity of the subjective symptoms of dizziness was assessed by the DHI scale and VAS was used to assess the severity of the subjective symptoms of dizziness and dizziness. Subsequently, cognitive function was assessed using Addenbrooke’s Cognitive Function Test Scale (ACE-R). Finally, possible predictors of migraine (vestibular) were evaluated by binary logistic regression analysis.
Results: It can be seen that vestibular migraine mostly female,the average age (40.6 ± 9.87) years old.The levels of plasma CGRP in patients with vestibular migraine were higher than those in normal subjects (P<0.05).
Conclusions: First, the vestibular migraine is highly correlated with mid-menopausal women, and the serum CGRP in patients with vestibular migraine is significantly higher than that of the healthy controls. It is an important predictor of vestibular migraine. In addition, the cognitive level of patients with vestibular migraines was significantly reduced.
PP2-115 - Clinical characteristics of vestibular migraine based on Barany diagnostic criteria
24. Vestibular Migraine
Bo Shen
1
Xu Yang1
1 Department of Neurology, Aerospace Center Hospital, Peking University Aerospace School of Clinical Medicine, Beijing,China.
Purpose: To investigate clinical features of vestibular migraine (VM) based on Barany diagnostic criteria.
Methods: Baseline data of 50 patients with vestibular symptoms accompanied by migraine/migraine features were collected. Videonystagmusgraphy, including head shaking nystagmus (HSN) and caloric test, and immunological examination were performed.
Results: Among 50 patients, 29 (58.0%) VM and 6 (12.0%) probable VM. In VMthe mean age of onset of vestibular symptoms was 39.4 years, while that of migraine was 34.8 years. Migraine occurred earlier than vestibular symptoms in 17 patients (58.6%). Vestibular symptoms presented spontaneous vertigo in 15 (51.7%), positional vertigo in 10 (34.5%), dizziness with nausea in 5 (17.2%), visually-induced vertigo in 1 (3.4%), postural symptoms in 5 (17.2%). The duration of vertigo attacks was less than 5 minutes in 3 (10.3%), 5 minutes~24 hours in 18 (62.0%), up to 24 hours in 8 (27.6%).Patients referred accompanying migraine features: headache (13/29, 44.8%), photophobia (24/29, 82.8%), phonaphobia (23/29, 79.3%) and visual aura (11/29, 37.9%). The incidence of motion sickness was 58.6% (17/29).The positive-rate of HSN was 48.3% (14/29); Peripheral vestibule was damaged in 12(41.4%). Severe autonomic nervous symptoms after caloric test appeared in 19 (65.5%).The abnormal-rate of immunology was 20.7% (6/29), positive-rate of thyroid antibodies was 83.3% (5/6).
Conclusions: The age of onset of migraines is earlier than vestibular symptoms in VM. Patients always have a history of motion sickness and severe autonomic nervous symptoms after caloric test. Many patients of VM may be accompanied by peripheral and systemic diseases, presumably there is a diagnosis of secondary/concomitant VM.
PP2-116 - Differences between patients who have vestibular migraine and those who migraine only
24. Vestibular Migraine
Pınar Özçelik1
Koray Koçoğlu2, Vesile Öztürk1,
Gülden Akdal
1
1 Dokuz Eylül University Hospital Neurology Department, İzmir-Turkey
2 Dokuz Eylül University Health Sicences Institute Department of Neuroscience, İzmir, Turkey
Purpose: Our hypothesis is that there are differences between patients with vestibular migraine (MV) and those who have no vestibular symptoms i.e. – that is migraine headaches only (MO).
Methods: We evaluated 35 VM and 35 MO patients on the following: (a) Migraine Disability Assessment (MIDAS); (b) Allodynia Symptom Checklist (ASC-12), (c) Beck Depression Inventory (BDI); (d) State-Trait Anxiety Inventory (STAI); (e) Health anxiety inventory (HAI); (f) World Health Organization Quality of Life Questionaire Short Form (WHOQL-SF12); (g) Activities Specific Balance Confdence scale (ABC). Dizziness Handicap Inventory (DHI) was assessed in only VM patients.
Results: In 22 VM patients the diagnosis migraine was first made during evaluation in our Balance Disorder Clinic. Specific food triggers were noted (for both headache or vertigo) by 8 VM patients but not by any of the MO patients. Of the VM patients 17/35 had headache with the vertigo. The onset headaches was later in life in VM than in MO patients (GIVE MEAN IN YEARS p:0.038). BDI was higher in VM whereas STAI was higher in MO. On the other hand, MIDAS, HAI, ASC-12 and WHOQL-SF12 were no different. ABC Scale was low and DHI showed moderate disability (highest in functional scale) in VM patients. MIDAS score and DHI- functional part were positively correlated.
Conclusions: Migraine diagnosis is often made only after consultation in a balance disorders climic shows that neurootologist should always take a headache history. Certain food triggers for both headache and vertigo in VM patients attracts attention to allergy. DHI confirms the need for vestibular rehabilitation.
PP2-117 - Do the inflammatory factors contribute to the pathogenesis of vestibular migraine?
24. Vestibular Migraine
Zerrin Karaaslan1
Pınar Özçelik2, Çağrı Ulukan3, Canan Ulusoy4, Kadir Serhan Orhan5, Elif Kocasoy Orhan1, Cem İsmail Küçükali6, Erdem Tüzün6, Betül Baykan1,
Gülden Akdal
2
1 Istanbul Faculty of Medicine, Department of Neurology, Istanbul/Turkey
2 Dokuz Eylül University Faculty of Medicine, Department of Neurology, Izmir/Turkey
3 Istanbul University, Institute of Experimental Medicine, Department of Neuroscience , Istanbul/Turkey
4 Istanbul University, Institute of Experimental Medicine, Department of Neuroscience, Istanbul/Turkey
5 Istanbul Faculty of Medicine, Department of Otorhinolaryngology , Istanbul/Turkey
6 Istanbul University, Institute of Experimental Medicine, Department of Neuroscience, , Istanbul/Turkey
Purpose: Vestibular migraine (VM) is an under-recognized entity with substantial burden for the individual and society. The underlying mechanism of VM and its distinction from other migraine mechanisms still remained unclear. Studies revealed that inflammatory pathways contribute to migraine. We aimed to investigate the possible role of inflammation in the pathophysiology of VM compared to migraneurs without history of vertigo-migraine only (MO) and healthy controls (HC).
Methods: We recruited 25 patients with MO and 32 with VM, diagnosed according to ICHD-3beta criteria and 26 sex- and age-matched HC. Blood samples could be obtained only from 12 patients during the attack, whereas the remaining samples were taken in headache-free periods. Plasma levels of CGRP, NKA, Substance P (SP), NLPR-1, NLPR-2,CASP-1, IL-1b, IL-6, IL-8, IL-10, TNF-α, IF-γ, NFκB were measured with the commercial kits by following the manufacture’s instructions.
Results: Inflammatory cytokines were found positively correlated with inflammasome pathway in both VM and migraine groups. TNF-α and IL-6 were both suppressed in VM and MO while SP was reduced only in MO patients when compared to HC. Furthermore, inflammasome pathway factors were correlated with allodynia in patients with VM. Prophylactic treatment had no effect on cytokine levels.
Conclusions: Inflammatory cytokines were found positively correlated with inflammasome pathway in both VM and migraine groups. TNF-α and IL-6 were both suppressed in VM and MO while SP was reduced only in MO patients when compared to HC. Furthermore, inflammasome pathway factors were correlated with allodynia in patients with VM. Prophylactic treatment had no effect on cytokine levels.
PP2-118 - Is it possible to differentiate vestibular migraine from Meniere’s disease neurophysiologically?
24. Vestibular Migraine
TOSHIHISA MUROFUSHI
1
MASAHITO TSUBOTA1, RYOTA SUIZU1, Yukiko Tsuda2, Eriko Yoshimura2
1 Department of Otolaryngology, Teikyo University School of Medicine Mizonokuchi Hospital, Japan
2 Yoshimura ENT Clinic, Japan
Purpose: Meniere’s disease (MD) and vestibular migraine (VM) are representative diseases presented with episodic vertigo attacks. Their clinical diagnoses basically depend on medical history. In this situation, objective tests which enable clinicians to differentiate two diseases using neurophysiological methods are required. For differential diagnosis of MD and VM, we studied tuning property of cervical vestibular evoked myogenic potentials (cVEMP) (Part 1) and habituation in auditory middle latency responses (MLR) (Part 2).
Methods: Subjects were patients with definite MD or VM. Part 1. To study tuning property of cVEMP, normalized cVEMP amplitudes (p13-n23) to 500Hz short tone bursts (STB) were compared with those to 1000Hz STB, 500-1000Hz cVEMP slope as an index of tuning property was calculated. Part 2. MLRs were recorded to assess habituation in MLRs. Totally, 800 responses were averaged. Recordings were divided into 4 sets according to the order of recording. Peak-to-peak amplitudes in MLR to the first 200 resopnses were compared with those to the 2nd, third and fourth 200 responses.
Results: Part 1. MD patients showed tendency of larger responses to 1000Hz STB than 500Hz STB although VM patients showed tendency of larger responses to 500Hz STB. Part 2. While MD patients showed reduction of Na-Pa amplitudes in the fourth set to amplitudes in the first set, VM patients rather showed augmentation of Na-Pa amplitudes in the fourth set.
Conclusions: Detection of tuning property shift using cVEMP tuning property test and detection of lack of habituation using auditory MLR might be neurophysiological methods of differentiation between MD and VM.
PP2-119 - Postural instability evoked by visual motion stimuli in patients with vestibular migraine
24. Vestibular Migraine
Sung-Hee Kim
1
Yong-Hyun Lim1
1 Department of Neurology, Kyungpook National University School of Medicine, Kyungpook National University Chilgok Hospital, Daegu, Republic of Korea
Purpose: Patients with vestibular migraine are highly susceptible to motion sickness. It has been hypothesized that motion sickness occurs from instability in the control of the posture of the body or its segments. This study aimed to determine whether the severity of posture instability are related to the susceptibility to motion sickness.
Methods: This study enrolled 18 patients with vestibular migraine (16 women, age of 45.67 ± 12.55 years) who met the diagnostic criteria produced by a working group of the Barany Society. We used a visual motion paradigm with two conditions of the stimulated retinal field and the head posture to quantify postural stability while maintaining a static stance in healthy subjects and in patients with vestibular migraine. Sixteen healthy volunteers (10 women, age of 34.94 ± 10.29 years) served as the controls.
Results: In contrast to the controls, patients with vestibular migraine showed marked postural instability of the head and neck when visual stimuli were presented in the retinal periphery. However, the pseudo-Coriolis effect induced by head roll tilt was not responsible for the main differences in postural instability between patients and controls.
Conclusions: Patients with vestibular migraine had a higher visual dependency and low stability of the postural control system when maintaining quiet standing, which may be related to susceptibility to motion sickness.
PP2-120 - The differences of clinical characteristics between Vestibular migraine and Meniere’s Disease
24. Vestibular Migraine
XIULI LIU
1
XIAO YU1, LIN SHI1
1 Department of Otolaryngology, First Affiliated Hospital of Dalian Medical University, Dalian 116011, China
Purpose: To distinguish VM from MD by comparing audiological and vestibular test results in patients with both.
Methods: 60 patients of VM group and 80 patients of MD group were studied.All the patients were tested with bithermal caloric test,vHIT and audiological test,some patients were tested with VEMP in acute or subacute phase.
Results: The sex ratio of VM and MD were 1:9.3 and 1:1.08.Family history of VM and MD patients were 66.67% and 7.5% respectively.Thirty-one percent of the VM patients in this study had abnormal bithermal caloric test findings,88.33% abnormal vHIT,50% abnormal cVEMP,88.64 abnormal oVEMP.In the MD group,the abnormal rates of these four tests were 77.5%,50%,61.11% and 50% respectively.The difference of bithermal caloric test,vHIT,oVEMP between VM and MD was statistically significant, and the difference of cVEMP abnormal rate was not statistically significant.Sensorineural hearing loss was present in 63.3% of VM patients.Among them,the pattern of hearing loss was flat in 39.5% of patients,low frequency in 13.2% and high frequency in 47.4%.
Conclusions: In VM patients,there are more females than males, and sex ratio of the MD patients is basically the same.Compared with MD patients,there is an obvious family history of VM patients.Both VM and MD patients can have semicircular canal and otolith organ function abnormality.vHIT and oVEMP have higher abnormality rate in VM patients, and the bithermal caloric test has higher abnormality rate in MD patients.Both the VM patients and the MD patients have different levels of hearing loss.The hearing curve of VM is various and the hearing loss of high frequency is more serious.
PP2-121 - The Research of Cognitive Change and Imaging Features in patients with (vestibular) migraine
24. Vestibular Migraine
Zhang Jun Li
1
1 Harbin Medical University, Harbin, China
Purpose: it has been demonstrated that the cognitive function changes of many patients has different performance in different regions of functional magnetic resonance imaging, the aim of this study was to examine the association between cognitive function changes in patients with migraine and migraine-associated vertigo and the corresponding functional magnetic resonance.
Methods: In total,30 patients with migraine and migraine-associated vertigo were consecutively recruited. After admission, functional magnetic resonance imaging was performed.The ACE-R cognitive function scale was used to examine patients’ cognitive function changesA total of 10 healthy controls were also recruited and the cognitive function and functional magnetic resonance measurements were measured.
Results: 1.The metabolism of temporal-apex-island region and bilateral thalamic region in patients with vestibular migraine was more than normal people. The patient’s vestibular thalamus - cortical pathway was activated, abnormalities of the thalamic functional area appeared after vestibular stimulation, and its intensity was positively correlated with the frequency of vestibular stimulation.2.The resting fMRI study of patients with vestibular migraine during the episode showed a decrease in activation of cognitive-related occipital and frontal lobes (eg, hippocampal areas responsible for spatial memory and navigation).3.Temporal gray matter volume, cingulate gyrus, dorsolateral forehead, insula, and occipital lobe cortex were all decreased in patients with vestibular migraines. All of these brain regions suggest that they are associated with cognitive decline in patients with vestibular migraine.
Conclusions: It was found that the change of cognitive function in patients withvestibularmigraine was related to the functional magnetic resonance.
PP2-122 - Unique findings of video head impulse test during the ictal period of vestibular migraine
24. Vestibular Migraine
Seunghee Na
1
Eek-Sung Lee2, Ki-Bum Sung2, Tae-Kyeong Lee2
1 Department of Neurology, Incheon St. Mary’s Hospital, The Catholic University of Korea, Incheon, Korea
2 Department of Neurology, Soonchunhyang University College of Medicine, Bucheon, Korea
Purpose: Vestibular migraine (VM) is a common disorder presenting recurrent episodes of vertigo and headache. There are several reports of clinical and neuro-otologic findings in VM.
Methods: A 40-year-old man with vestibular migraine visited the emergency department due to vertigo. He had nausea, vomiting and a slight imbalance, but had no auditory symptoms. His symptoms met the criteria of vestibular migraine according to the Barany Society’s diagnostic criteria.
Results: He showed prominent spontaneous nystagmus with caloric canal paresis and vestibulo-ocular reflex deficit by rotatory chair test during the ictal period. In addition, a video head impulse test revealed “early acceleration and premature deceleration” during stimulation of the left posterior canal. The spontaneous nystagmus increased during leftward gaze and convergence, but decreased during rightward gaze. Positional maneuvers augmented the spontaneous nystagmus and induced a down-beating component during head bending while sitting. Two days after onset, his vertigo and the spontaneous nystagmus had disappeared, but he complained of migrainous headache lasting for 24 hours. On follow-up vHIT, the VOR gain and the peak velocity of “early acceleration and premature deceleration” were also improved.
Conclusions: Since unilateral HC dysfunction does not coexists with ipsilateral PC hyperactivity physiologically, the vHIT finding in our patient during the ictal period suggests that central and peripheral vestibular syndromes were present simultaneously. In summary, our vestibular migraine patient showed “early acceleration and premature deceleration” on vHIT during the ictal period. This response may be considered a subsidiary sign, suggesting central vestibular syndrome beyond the VOR deficits.
PP2-123 - Vestibular Migraineurs journey from symptom to diagnosis; long frustrating and often disappointing
24. Vestibular Migraine
Mahsa Bakhit1
Jessica Jane Vitkovic1, Caitlin Barr2, David Szmulewicz3
1 The University of Melbourne, Department of Audiology and Speech Pathology, Melbourne, Australia.
2 The University of Melbourne, HEARing CRC, Department of Audiology and Speech Pathology, Melbourne, Australia.
3 The University of Melbourne, The Royal Victorian Eye & Ear Hospital, Department of Neuroscience (LR), St Vincent’s Hospital, Melbourne, Australia.
Purpose: To investigate Vestibular Migraineurs’ experience with various healthcare professionals (HCPs) and to identify probable obstacles that once addressed, will improve patients’ experience with HCPs.
Methods: Semi-structured interviews were conducted with 11 patients. Audio-recordings of the interviews were transcribed and analyzed using qualitative content analysis.
Results: Analysis resulted in six major themes; 1) Frustration by frequent misdiagnosis and numerous referrals 2) Dismissive behaviours and poor management by practitioners especially General Practitioners (GPs) 3) Patients assuming responsibility for their diagnosis/treatment due to scepticism towards non-specialized practitioners’ competency, 4) Satisfaction by Vestibular Specialists’ (VSs) practice 5) Expectations from HCPs 5) Multi-faceted function of a formal diagnosis. The results indicated that most GPs either fail to recognize VM as a differential diagnosis of recurrent vertigo, lack the confidence to manage it or have uncertainty about which specialists to refer the patients to. The consequences are unnecessary lengthening of the patients’ illness experience and increased burden on the health system.
Conclusions: We propose the following recommendations to address this issue: 1) improve practitioners’ knowledge especially GP’s on how to differentiate VM from other vestibular disorders via training courses. 2) Informing HCPs about Vestibular Specialists’ scope of practice for more accurate referrals, 3) Provide online patient resources that will help HCPs to accurately evaluate the symptoms, help the patients ask the right questions from their doctor or choose their vestibular healthcare provider.
PP2-124 - VHIT in Vestibular migraine - Overt and covert saccades with increased gain.
24. Vestibular Migraine
Eu Chin Ho
1
Lee Huan Tee1
1 Tan Tock Seng Hospital
Purpose: Video Head Impulse Test (VHIT) was originally designed to help in the diagnosis of vestibular hypofunction. The application of VHIT in vestibular migraine patients is explored in our study.
Methods: 10 patients with clinical history consistent with Definite Vestibular Migraine according to the 2012 Consensus Diagnostic criteria agreed on by the Barany Society and International Headache Society were also investigated with VHIT and caloric.
Results: All patients underwent a thorough clinical examination including Halmagyi Head Thrust, post head shake nystagmus, Dynamic Visual Acuity, Romberg’s test and Oculomotor evaluation. All patients had catch up saccades on Halmagyi Head Thrust either unilaterally or bilaterally and Dynamic Visual Acuity drop of 3 lines or more. Whilst this may be suggestive of bilateral vestibular hypofunction, no post head shake nystagmus were elicited and they had normal foam Romberg’s eyes shut examination.
All patients were found to have overt and covert saccades in multiple canals on VHIT testing with the Interacoustic VHIT equipment. However, all of them have normal or increased gain, some as high as over 2. None of them have gain less than 0.9. Caloric test in all patients also confirmed no vestibular hypofunction. The presence of catch up saccades in Vestibular Migraine is not well understood but may be related to intolerance to sudden head movement which is part of the sensory amplication phenomenon experienced by migraine patients.
Conclusions: Patients with clinical history suggestive of vestibular migraine with mixed clinical examination findings should have the VHIT to confirm there is no vestibular hypofunction.
PP2-125 - Diagnosing peripheral vestibular dysfunction by assessing 3D body tracking via Kinect v2
25. Vestibular Neuritis
Mariya Chepisheva
1
Min Xiang1, Letizia Gionfrida2, Hannah Streat1, George Waddell2, Aaron Williamon2, Danilo Mandic3, Anil Bharath2, Barry M Seemungal1
1 Imperial College London, Faculty of Medicine, Division of Brain Sciences, London, United Kingdom
2 Royal College of Music, London, United Kingdom
3 Imperial College London, Faculty of Engineering, Department of Electrical and Electronic Engineering, London, United Kingdom
Purpose: Normal human locomotion requires a complex interaction of the visual, vestibular and proprioceptive systems together with the neural circuits coordinating locomotion. When one of these components malfunctions, gait abnormalities occur. Peripheral vestibular dysfunction (PVD) is a common disorder that affects gait and balance. Therefore, a well- tolerated, easy to operate (user-friendly) and low cost method that can diagnose peripheral vestibular dysfunction is needed so that non-experts in the community can also use it for diagnosis. In order to achieve this goal we decided to use the low-cost Microsoft Kinect v2 sensor for tracking body movements in PVD patients.
Methods: This is an ongoing study in PVD patients and healthy controls. PVD patients worsen their performance for tasks that are vestibular-dependent if other sensory input (e.g. vision) is removed. Hence, we assess gait performance in the light vs. the dark for a simple protocol of clinical tests including the Romberg and Unterberger’s tests.
Results: We predict that the worsening of gait and postural parameters measured by Kinect v2 in the dark vs. the light will be greater and easily detectable in PVD patients compared to healthy controls.
Conclusions: Gait is an important parameter and its accurate measurement in PVD patients with Microsoft Kinect v2 is likely to provide useful diagnostic information.
PP2-126 - Diplopia from skew deviation in peripheral vestibulopathy
25. Vestibular Neuritis
JIYUN PARK
1
1 Ulsan University/Ulsan University Hospital/ Department of Neurology
Purpose: Although skew deviation is well described in brainstem lesions, the phenomenon can also result from peripheral vestibular lesions. But it rarely has been reported in the literature. The authors report the case of a 63-year-old woman with peripheral vestibulopathy who developed binocular vertical diplopia with skew deviation and incomplete OTR.
Methods: A 63-year-old female presented vertical diplopia without focal neurologic signs for 3 days. Neurologic examination showed commitant hypotropia of the left eye without nystagmus or head tilt.
Results: Fundus photography showed counter-clock wise ocular torsion and SVV tilt were shown toward the left. Caloric test showed normal response. v-HIT showed normal except low gain and corrective saccade of left PC. Amplitude of cVEMP (p13-n23) decreased in the left side. Abnormal findings of cVEMP and v-HIT returned to normal 2 weeks later. These results mean inferior vestibular dysfunction with otolith dysfnction. Serological examinations and brain MRI including angiography were normal.
Conclusions: In this patient, skew deviation and tilt of the static visual vertical were interpreted as signs of an acute unilateral selective(inferior division) vestibular dysfunction including otolithic dysfunction. We thought that her distinct diplopia was due to no apparent nystagmus because the horizontal canal pathway was sparing.
PP2-127 - Disability and neuritis, prognostic factors
25. Vestibular Neuritis
Bernard Cohen
1
1
Purpose:
Methods:
Results:
Conclusions:
PP2-128 - Functional MR Spectroscopy of the Primary vestibular Cortex in Patients with vestibular neuritis
25. Vestibular Neuritis
Youngmin Hah
1
Young Seok Byun1, Sang Hoon Kim1, Seung Geun Yeo1, Moon Suh Park1, Jae Yong Byun1
1 Department of Otorhinolaryngology - Head & Neck Surgery, School of Medicine, Kyung Hee University, Seoul, Korea
Purpose: This study was designed to evaluate MR spectroscopic biochemical changes in patients with acute vestibular neuritis (VN) as compared with healthy volunteers. It is also designed to know metabolites concentrations changes and to evaluate the correlation between the grade of peripheral vestibular assessment and the concentration of metabolite in patients with acute unilateral VN.
Methods: Included 33 individuals who visited Kyung-Hee medical center at Gang-Dong from Mar.2016 to Mar.2017. We performed MR imaging and HMR 1 spectroscopy of the brain in VN patients. Single-voxel MR spectroscopy was used to study biochemical changes in the primary vestibular cortex and cerebellum in 13 control subjects and 20 patients with acute VN.
Results: There are no significant alteration of all brain metabolites between VN group and control group. The mi/H2O, mi/Cr ratio was lower in the primary vestibular cortex of lesion side when comparing those of contralesional side in acute stage of VN patients. The NAA/Cr ratio was higher in the lesion side when comparing those of contralesional side in acute VN. Correlation between Caloric CP and alteration of some metabolite concenstraion in VN patients showed the statistically significant (Cho/Cr, Cho/H2O, Cho/NAA, ml/Cr, ml/H2O, NAA/Cr).
Conclusions: Myosinositol of lesion side was decreased and ratio of NAA to Cr was increased significantly when comparing those of contralesional side in VN patients. There are significant correlation between alteration of some brain metabolite like a cholin, ratio of NAA to Cr and degree of canal paresis. So we could consider these metabolites would be biologic marker of acute VN.
PP2-129 - Genome-wide Association Study in Vestibular Neuritis
25. Vestibular Neuritis
Dan Rujescu1
Annette M. Hartmann2, Ina Giegling1, Bettina Konte2, Marko Herrling3, Susanne Himmelein4,
Michael Strupp
4
1 University Hospital Munich, German Center for Vertigo and Balance Disorders, Germany; Martin-Luther-University Halle-Wittenberg, Department of Psychiatry, Psychotherapy and Psychosomatics, Germany
2 Martin-Luther-University Halle-Wittenberg, Department of Psychiatry, Psychotherapy and Psychosomatics, Germany
3 University Hospital Munich, German Center for Vertigo and Balance Disorders, Germany
4 University Hospital Munich, German Center for Vertigo and Balance Disorders, Germany; University Hospital Munich, Department of Neurology, Germany
Purpose: In order to identify genetic variants associated with vestibular neuritis, a common cause of peripheral vertigo with a potential causative link to the reactivation of herpes simplex type 1 (HSV-1), we conducted a genome-wide association study.
Methods: Association was assessed using app. 8 million single nucleotide polymorphisms after imputation in 7 batches. 131 patients with vestibular neuritis and 2609 controls of European ancestry were included.
Results: Genome-wide associations with vestibular neuritis were detected in 5 regions containing protein coding genes assignable to two functional groups: virus hypothesis and insulin metabolism.
Genes of set 1 are related to viral processes: NR3C2 is a receptor for mineralocorticoids and glucocorticoids and was shown to be a host factor for HSV-1 replication. ANKRD30A is a host factor for human immunodeficiency virus-1 (HIV-1) infection. It shows rapid evolution and is induced by interferon stimulation. MED30 is an essential member of the mediator complex and has been shown to be involved in replication of HIV-1, a knockdown leading to impaired viral replication. The second set of genes (LMX1A, SLC30A8, HTR2C) is associated to insulin metabolism and resistance, a feature of some patients with type 2 diabetes as an accompanying comorbidity of vestibular neuritis.
Conclusions: Using a different approach to evaluate the etiology of vestibular neuritis these findings give another piece of evidence that it may be caused by a viral inflammation.
PP2-130 - Steroids for acute vestibular neuronitis - the earlier the treatment, the better the outcome?
25. Vestibular Neuritis
Julia Sjögren
1
Måns Magnusson1, Mikael Karlberg1, Fredrik Tjernström1
1 Skåne University hospital, Lund, Sweden
Purpose: To present findings that suggest steroid treatment within 24 hours of onset of vestibular neuronitis results in better restitution of vestibular function than treatment between 25 to 72 hours.
Methods: 33 consecutive patients (17 men, 16 women, mean age 57 years, range 17-85 years) with acute vestibular neuronitis and treated with steroids within 72 hours after symtom onset. Patients were divided into 2 groups depending on if they were treated within the first 24 hours or not.
Oral prednisolone 50 mg/day for 5 days with tapering of doses for the next 5 days, or combined with initial intravenous betamethasone 8 mg the first 1 to 2 days if the patient was nauseous.
Results: All 9 patients (100%) treated within 24 hours from onset of vestibular neuronitis had normal caloric test results at follow-up, as compared to 16 of 24 (66%) of the patients treated between 25-72 hours (p<0,05, chi2-test).
Conclusions: The timing of steroid treatment of vestibular neuronitis may be of importance for subsequent vestibular restitution, and hence, for both time to recovery and late symptoms according to the literature.
PP2-131 - The clinical efficacy of vestibular function tests in patients with acute peripheral vestibulopathy
25. Vestibular Neuritis
Bong-Hui Kang
1
Jae-Il Kim1
1 Department of Neurology, School of Medicine, Dankook University
Purpose: Aim of this study is to investigate the clinical efficacy of the vestibular function tests and the predictability of lesion side of vestibular asymmetry parameters in acute peripheral vestibulopathy .
Methods: The medical records and vestibular function test results of 62 patients with acute unilateral peripheral vestibulopathy were retrospectively reviewed. The caloric, rotatory chair, posturography, bedside and video HITs were examined within 7 days after the clinical onset.
Results: For the caloric test, 79% showed significant canal paresis and the predictability of lesion side was 84%. For the sinusoidal harmonic acceleration test, 97% had low gain in at least one Hz, phase lead showed 66%, 93% showed phase asymmetry and the predictability of lesion side was 85%. For velocity step test, 66% had abnormal Tc asymmetry and the predictability of lesion side was 95%. In bedside HIT, abnormal catch up saccades were observed in 92% and the predictability of lesion side was 100%. For the video HIT, cover or overt catch-up saccades were observed in 96% and the predictability of lesion side was 100%. 100% had low gain on the video HIT, but the lesion sides were uncertain because of bilateral involvements. 91% showed vestibular dysfunction on sensory analysis of posturography.
Conclusions: The most important things about the diagnosis of acute peripheral vestibulopathy are typical clinical symptoms and spontaneous nystagmus. Only a single test has insufficient sensitivity and predictability of lesion side. Among them, head impulse test is considered the best in acute unilateral peripheral vestibulopathy.
PP2-132 - Vestibular function features and prognosis of vestibular neuritis in children
25. Vestibular Neuritis
Bing Liu
1
Wei Liu2, Min Chen2, Jie Zhang2
1 Beijing Children’ s Hospital, Capital Medical University, Department of Otorhinolaryngology Head and Neck Surgery, China
2 Beijing Children’ s Hospital, Capital Medical University, Department of Otorhinolaryngology Head and Neck Surgery, China
Purpose: Investigate the clinical characteristics, prognosis and affected branches of vestibular neuritis in children.
Methods: Twenty-five patients with vestibular neuritis in ENT department, Beijing Children’s Hospital, from October 2015 to October 2016 were collected. The clinical manifestations recorded, pure tone audiometry , bithermal caloric test, cervical and ocular vestibular-evoked myogenic potential (cVEMP and oVEMP) were done for every patients. We also took the blood sample for pathogenic virus for those who had upper respiratory tract infection or intestinal infection history.
Results: Twenty-five patients were 4~14 years old (mean 9.8) . There were 17 cases with vomiting and 19 cases with balance dysfunction. Twenty patients had respiratory tract or intestinal infection history. In 20 blood samples for virology, 4 cases of herpes simplex virus and 6 cases of influenza B virus were identified. Bithermal caloric test was abnormal in 18 cases. The oVEMP in 12 cases and cVEMP in 5 cases were abnormal. All patients recovered well, but the time differed.The symptoms of 21 patients were complete recovery within 1 month. 3 patients were complete recovery within 3 months (aged 8 ~ 14 years old). One patients was complete recovery within 6 months (aged 13 years old).
Conclusions: The vestibular neuritis in children may be related with respiratory tract infection. The most common affected branch was superior vestibular nerve, and two branches, superior and inferior vestibular nerve were secondly involved , which is the same as that of adults. The younger patients with VN recovered more quickly than that in the older.
PP2-133 - Video Head Impulse Test and Cervical Vestibular Evoked Myogenic Potential in Vestibular Neuritis
25. Vestibular Neuritis
Min-Beom Kim
1
Jin Su Park1, Sun O Chang1
1 Department of Otolaryngology-Head and Neck Surgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea.
Purpose: To evaluate and compare the results of cervical vestibular evoked myogenic potential (cVEMP) and video head impulse test (p-vHIT) of posterior semicircular canal plane in acute vestibular neuritis
Methods: Seventy-nine patients with vestibular neuritis participated in this study. We analyzed the interaural amplitude difference in cVEMP with a positive rate of p-vHIT according to gain and corrective saccade in the study population. To evaluate the concordance rate of both tests, we analyzed Fleiss’ Kappa value inter-test agreement of cVEMP with p-vHIT. Finally, we performed detailed analysis of the bilaterally absent response on cVEMP according to the p-vHIT results.
Results: The inter-test agreement between cVEMP and p-vHIT was 69.8% as we also considered the lesion side. This result indicated a statistically fair to good agreement in both tests. In mostly elderly patients with a bilaterally absent response (11 patients) on cVEMP, as a result of vHIT, nine patients with a bilaterally negative response on p-vHIT showed only canal paresis. Two patients showed canal paresis and a unilaterally positive response on p-vHIT.
Conclusions: Inter-test agreement between cVEMP and p-vHIT assessed in vestibular neuritis was relatively lower than we had predicted. Probably, p-vHIT can provide additional information on the differential diagnosis of dysfunction of the inferior vestibular nerve which is composed of the saccular nerve and the posterior ampullary nerve.
PP2-134 - Controlled postural responses upon electrical stimulation with a vestibular implant in humans
26. Vestibular Prosthesis
Nils Guinand
1
Stéphane Armand2, Maurizio Ranieri1, Samuel Cavuscens1, Raymond van de Berg3, Herman Kingma3, Jean-Philippe Guyot1, Angelica Perez Fornos1
1 Cochlear Implant Center for French Speaking Switzerland, Division of Otolaryngology-Head & Neck Surgery, Department of Clinical Neurosciences, Geneva University Hospitals, Geneva, Switzerland
2 Willy Taillard Laboratory of Kinesiology, Department of Clinical Neurosciences, Geneva University Hospitals and Geneva University, Geneva, Switzerland
3 Division of Balance Disorders, Department of Otorhinolaryngology and Head and Neck Surgery, School for Mental Health and Neuroscience, Maastricht University Medical Center, Maastricht, Netherlands
Purpose: To investigate the possibility of evoking controlled postural responses using electrical stimulation delivered by a vestibular implant prototype in humans.
Methods: A female patient with bilateral vestibular hypofunction (71 years old) received a prototype vestibular implant providing 3 electrode branches implanted in the ampullae of the 3 semicircular canals (left ear). Postural responses were evaluated during 20s trials of the Unterberger test without any electrical stimulation and upon electrical stimulation (charge-balanced biphasic pulse trains, 200µs/phase, 400 pulses-per-second) at different current intensities (300µA, 325µA, 375µA, 400µA) up- and down-modulated around a constant baseline current (350µA). Whole-body postural responses were recorded using a 12-camera motion capture system (Oqus7+, Qualisys AB, Göteborg, Sweden).
Results: Without electrical stimulation, the angular rotation of the patient’s trunk was 3.6° ± 3.6° (mean ± standard deviation; clock-wise). We observed a significant negative correlation between current intensity and trunk rotation (Pearson product-moment correlation r=-0.92, n=14, p<0.0001), reaching values of 31.6° ± 5.8° for maximum down-modulation and -8.33° ± 10.8° for maximum up-modulation. Linear body motion (distance and direction) was variable and uncorrelated to electrical stimulation. Results for head motion were practically identical, demonstrating that the patient’s whole body moved “in-bloc”.
Conclusions: These results demonstrate, for the first time in humans, that whole-body motion can be controlled and modulated using electrical stimulation delivered to the ampullary nerves in humans. These results are very encouraging, suggesting that vestibular implants could potentially provide useful cues to address disabling postural deficiencies (e.g., imbalance) and consequently decrease fall risks.
PP2-135 - Effects of long-term noisy vestibular stimulation on body balance in bilateral vestibulopathy
26. Vestibular Prosthesis
Shinichi Iwasaki
1
Chisato Fujimoto1, Naoya Egami1, Takuya Kawahara2, Yukari Uemura2, Yoshiharu Yamamoto3, Tatsuya Yamasoba1
1 University of Tokyo, Department of Otolaryngology, Japan
2 University of Tokyo, Clinical Research Support Center, Japan
3 University of Tokyo, Graduate School of Education, Japan
Purpose: To examine the effects of long-term noisy galvanic vestibular stimulation (nGVS) on improving body balance after the cessation of the stimulus in patients with bilateral vestibulopathy (BV).
Methods: Thirteen BV patients underwent two nGVS sessions at 2-week interval. In each session, the BV patients received nGVS for 30 min and were monitored without stimuli for 6 h. Two-legged stance tasks were performed with eyes closed with and without nGVS. The velocity, area, and root mean square of the center of pressure (COP) movement were measured using posturography. The effect of nGVS on the frequency component of the COP sway were then investigated by power spectral analysis using maximum entropy method. Power spectral density (PSD) of the COP were calculated. Subjective improvement of body balance was also scored.
Results: In each session, the velocity of the COP movement was significantly improved for 6 h after the cessation of the stimulus. The mean frequency of postural movement was significantly smaller until 3 h after the cessation of the stimulus than at baseline, suggesting that the ameliorating effect of nGVS on the postural stability might have an association with the frequency shift of the COP sway to the lower frequency. The subjective symptom of imbalance was also improved during the post-stimulation effect of nGVS.
Conclusions: nGVS can lead to the improvement in body balance that lasts for several hours after the cessation of the stimulus in BV patients, especially in the velocity of the COP movement.
PP2-136 - Immediate efficacy of Gufoni maneuver for HC-BPPV: a meta-analysis
26. Vestibular Prosthesis
Wei Fu
1
Junliang Han2, Dong Wei2
1 Fourth Military Medical University,Xijing Hospital, Department of Geriatrics,China
2 Fourth Military Medical University, Xijing Hospital, Department of Neurology, China
Purpose: Gufoni maneuver is a very common and efficient treatment for horizontal canal benign paroxysmal positional vertigo(HC-BPPV), with which patients with either a canalolithiasis or a cupulolithiasis can be successfully treated. However, there is no evidence-based study to reveal the immediate efficacy of this maneuver for HCBPPV. Therefore,This meta-analysis aims to systematically measure the immediate efficacy of the Gufoni maneuver for HC-BPPV.
Methods: A extensive search electronic databases,including PubMed, Embase, Web of Science, Cochrane and Chinese medical databases, were searched until to September 1,2017 for relevant articles. we selected only randomized clinical trials studying with treatment of HC-BPPV employ by the Gufoni maneuver.
Results: Six randomized clinical trials were included in the current meta-analysis with a total of 696 HC-BPPV patients. The pooled odds ratio of efficacy (ORe) and odds ratio of otolith switch (ORos) were used to estimate overall therapeutic performance. The pooled ORes were 4.00 (95% CI, 2.05-7.78, p<0.01, Gufoni VS. Sham), 1.87(95% CI,0.42-8.33, p=0.41, Gufoni VS. Barbecue maneuver), while the pooled ORos was 2.17(95% CI, 0.55-8.53, p=0.27). Subgroup analyses showed that the respective pooled ORes were 3.51(95% CI,2.09-5.89, p<0.01) and 3.23(95% CI, 1.24-8.39, p<0.05) in groups of geotropic nystagmus and geonegative nystagmus.
Conclusions: Gufoni maneuver has a satisfactory immediate efficacy for HC-BPPV and doesn’t increase otolith switch.
PP2-137 - A Novel Tele-Dizzy Consultation Program in the Emergency Department using Portable Video-oculography
27. Others
Roksolyana Tourkevich
1
Anthony Brune1, Daniel Gold1, Susie Peterson2, Barabara Maliszewski2, Justin Bosley1, Jorge Otero-Millan1, Mehdi Fanai1, Dale Roberts1, David Zee1, David Newman-Toker1
1 Division of Neuro-Visual & Vestibular Disorders, Department of Neurology, Johns Hopkins University School of Medicine, USA
2 Department of Emergency Medicine, Johns Hopkins Hospital, USA
Purpose: Deploy a tele-dizzy consultation service to improve diagnosis of emergency department (ED) patients with acute dizziness/vertigo.
Methods: Case study of a systems-level quality improvement intervention. Pilot program included (1) defining a new care pathway; (2) securing leadership buy-in; (3) modeling quality and cost benefits; (4) conducting training and implementing technology; and (5) identifying barriers and lessons learned.
Results: (1) Defined care pathway for evaluating ED patients with dizziness/vertigo of suspected neurologic or peripheral vestibular etiology using portable video-oculography (VOG) in the ED, with urgent clinic referrals for unclear cases. (2) Secured buy-in of ED Department Directors at 5 health system hospitals. (3) Modeled health system reduction of 50 missed strokes and ~$1 million per year saved on unnecessary imaging and admissions. (4) Conducted training for ED technicians and implemented secure data platforms for eye movement recordings to be electronically transferred for review by clinical faculty using ‘store-forward’ telemedicine approach. (5) Identified need for culture change through local champions; method to sustain ‘critical mass’ of workforce trained; faculty and fellow staffing to sustain service availability on evenings/weekends; and novel billing mechanisms in hybrid payment system (mixed population-based budgeted and fee-for-service). Over six months at the pilot hospital site, we assessed 68 tele-dizzy consults, 43 with vestibular diagnoses. The response to the service by ED providers has been positive.
Conclusions: Bringing specialty expertise via tele-dizzy consultation using VOG based rapid triage to EDs is feasible. The next step is testing the hypotheses of improved access, higher quality, and lower costs.
PP2-138 - A Retrospective Study of a Multidisciplinary Chronic Dizziness Clinic and an Acute Dizziness Clinic
27. Others
Phillip Staibano
1
Daniel Lelli2, Darren Tse3
1 University of Ottawa, Faculty of Medicine, Canada
2 University of Ottawa, Division of Neurology, Department of Internal Medicine, Canada
3 University of Ottawa, Department of Otolaryngology – Head & Neck Surgery, Canada
Purpose: Vertigo remains a diagnostic challenge for emergency physicians and specialists. We describe, for the first time in Canada, the clinical characteristics of patients presenting with chronic and acute dizziness to both a multidisciplinary dizziness clinic (MDC) and a rapid access dizziness (RAD) clinic at The Ottawa Hospital (TOH).
Methods: We performed a retrospective review of all patients presenting to the MDC and RAD clinics at TOH from July 2015 to August 2017.
Results: We found that 211 patients (median age: 61 years old) presented to the RAD clinic and 292 patients (median age: 55 years old) presented to the MDC. In the RAD clinic, 63% of patients had peripheral dizziness, of which 55% had BPPV, and only one patient had functional dizziness. Interestingly, only 25% of RAD diagnoses were concordant with the emergency diagnoses; moreover, only 33% of RAD patients had HiNTs completed, while 44% had CT scans, of which only one patient had an abnormal finding. In the MDC, 28% of patients had vestibular dizziness and 21% had functional dizziness, of which 43% had PPPD. Moreover, 12% of patients with functional dizziness also suffered from comorbid severe anxiety and depression.
Conclusions: Dizziness is a heterogeneous disorder that necessitates multidisciplinary care. RAD clinics can serve to help patients with peripheral dizziness in an acute setting, while ensuring informative diagnostic tests are utilized. MDCs can provide prolonged care for patients with PPPD while helping to alleviate the significant psychiatric burden amongst patients with chronic dizziness.
PP2-139 - Brain tissue volume changes in astronauts after six months of exposure to microgravity
27. Others
Angelique Van Ombergen1
Steven Jillings1, Ben Jeurissen2, Elena Tomilovskaya3, Ria Maxine Rühl4, Jitka Annen5, Ekaterina Pechenkova6, Alena Rumshiskaya6, Liudmila Litvinova6, Inessa Kozlovskaya3, Ilya Rukavishnikov3, Valentin Sinitsyn6, Stefan Sunaert7, Paul M. Parizel8, Jan Sijbers2, Steven Laureys9, Peter Zu Eulenburg4, Floris Wuyts1
1 University of Antwerp, Antwerp University Research center for Equilibrium and Aerospace (AUREA), Belgium
2 University of Antwerp, iMinds-Vision Lab, Belgium
3 Russian Academy of Sciences, Institute for Biomedical Problems, Russia
4 Ludwig-Maximilian University of Munich, German Center for Vertigo and Balance Disorders, Germany
5 University of Liège, COMA Science Group - GIGA Consciousness, Belgium
6 Federal center of Treatment and Rehabilitation, Department of Radiology, Russia
7 University of Leuven, Department of Imaging and Pathology - Translational MRI, Belgium
8 Antwerp University Hospital, Department of Radiology, Belgium
9 University of Liège, COMA science group - GIGA consciousness, Belgium
Purpose: Long-duration spaceflight has a profound impact on human physiology. It is crucial to understand these effects as they pose a potential health risk for astronauts on long-duration missions. Only few investigations into the effect of spaceflight on the central nervous system have been conducted. We therefore performed a study using brain MRI scans of astronauts before and after spaceflight to assess brain tissue volume changes.
Methods: 10 astronauts were scanned before and after 6 months of exposure to microgravity. 10 healthy controls were scanned twice with a similar time interval. Data were acquired on a 3T GE MRI scanner by means of T1 weighted imaging and diffusion tensor imaging. SIENA analysis was performed to assess brain and ventricular volume change. Voxel-based morphometry was performed to assess regional changes in gray matter, white matter and CSF volumes. Diffusion tensor imaging was used to perform analysis of free-water and mean diffusivity.
Results: An increase in brain ventricular volume was noted after spaceflight compared to before. Gray matter volume decreases were observed in ventral areas of the brain, while increases were noted in dorsal areas. Opposite changes in CSF volume and mean diffusivity were noted in the same regions.
Conclusions: Our results indicate that the volume changes occur due to a redistribution of bodily fluids. This is in line with previous studies showing that microgravity causes an upward fluid shift and an upward mechanical shift of the brain. These findings might help explain the phenomenon of increased intracranial pressure in astronauts as a result of spaceflight.
PP2-140 - Central Vestibular Sensitivity affects Motion Sick Susceptibility through the Velocity Storage.
27. Others
Kenneth Chua Wei De
1
Tze Ling Kek2
1 Changi General Hospital, Department of Otolaryngology, Singapore
2 National University Health System, Department of Otolaryngology, Singapore
Purpose: To determine the effects of Central Vestibular Sensitivity (CVS) on Motion Sick Susceptibility (MSS), through the velocity storage’s function of prolonging Slow-Phase Eye Velocity (SPEV) and Perceived Rotational Duration (PRD), in healthy individuals with different motion sick susceptibility.
Methods: A quantitative descriptive single blind controlled design. All participants recruited, completed the motion sick susceptibility questionnaire (short) and had no reports of neuro otologic/vestibular history or non-corrected visual problems. 25 controls and 25 highly motion sick susceptible subjects were recruited and first screened for any peripheral vestibular (Horizontal Semicircular canal and Saccular function) and central disorders, using videonystagmography, video-head impulse and cervical vestibular myogenic potential tests. Next, participants were tested on the rotatory chair to obtain the Slow-Phase Eye Velocity Time Constant (SPEV TC) and Perceived Rotational Duration (PRD). Readings were then compared for significant differences between control and subject group.
Results: Results showed no significant difference in SPEV TC between control and subject group for slow and fast rotations. However, there was significant difference in the PRD between these two groups. Multiple regression analysis indicated that post-rotatory PRD and the number of motion sick symptoms reported were positively correlated with the degree of MSS and were hence, significantly strong predictors.
Conclusions: Highly MSS individuals were observed with elevated PRD in general, indirectly suggesting greater velocity storage efficiency, hence, greater CVS; CVS is therefore positively correlated with MSS. PRD could be a reliable clinical indicator of motion sick susceptibility and may help in the verification of therapeutic interventions at reducing susceptibility to motion sickness.
PP2-141 - Challenge and Limitation of the Emergent Care of Dizziness in a Hospital without Specialists
27. Others
Nami Matsumoto
1
Kazuhiko Kubo2, Masahiko Akagi1, Akira Fukuhara1, Sho Zaitsu1, Takamasa Yoshida2, Azusa Ikegami1
1 Department of Internal Medicine, Kuwamizu Hospital, Kumamoto, JAPAN
2 Department of Otorhinolaryngology and Neurotology, Chidoribashi General Hospital, Fukuoka, JAPAN
Purpose: Many patients with acute vertigo or dizziness are referred to Emergency Hospital in the world. However, all of hospitals with emergency department don’t have Otorhinolarygologist or Neurologist as specialists. Our hospital is certified by World Health Organization as a health promoting hospital and usually receives the patients with acute vestibular syndrome (AVS). The aim of this study is to extract the characteristics of those patients and to formulate more effective treatment system than a current that.
Methods: Retrospective electric records-based study was designed. The subjects with AVS were recruited from 2013 to 2016. We collected age, gender, diagnosis, admission, duration of admission, outcome etc. for descriptive statistics. This study was approved by our institutional ethics committee.
Results: We have experienced over 300 patients with AVS for four years. A half of them were admitted to soothe symptoms. Some critical disorders were examined at a first line, and we introduced them to specialists when we could not diagnose their diseases correctly. A big earthquake occurred at Kumamoto on April 16, 2016. 5.4 and 14.5 patients with AVS were referred per month before and after this catastrophe, respectively.
Conclusions: The hospitals without specialists play a great role for the management of patients with AVS because the number of specialists is limited. It may be important to cooperate with hospitals with specialists after first care in hospitals without specialist.
PP2-142 - Clinical characteristics of 26 cases with recurrent low frequency sensorineural hearing loss
27. Others
Hou-Yong Kang
1
Hong Chen1, Ying Pang1, Qi-Yuan ZHou1, Jia Li1, Jia-Qiu Dai1, Zi-Qi Chen1, Guo-Hua Hu1, Ji-Hong Zeng1
1 The First Affiliated Hospital of Chongqing Medical University, Department of Otorhinolaryngology, China
Purpose: The etiology of recurrent low frequency sensorineural hearing loss (RLFSNHL) is unknown. It is often admitted to hospital diagnosed as sudden sensorineural hearing loss. This aimed at retrospectively analyzing the clinical data of RLFSNHL in order to providing evidence-based clues for the diagnosis and treatment of such patients.
Methods: Such 26 patients in the First Affiliated Hospital of Chongqing Medical University from August 2013 to January 2018 were recorded. All patients had experienced more than two times admissions. Statistical analysis for demography, clinical data, audiological examination (26 cases, audiometry, ABR, DPOAE, ECochG and glycerol test), and MRI Scan (6 cases), VNG, glycerol test.
Results: 6 male and women 20 cases (average year 32.15, 25 unilateral and 1 bilateral) presented the chief discormfort as follow, low pitch tinnitus ( the first and second adimission respctively 21, 20), ear fullness (13,19), vertigo (2, 4), dizziness (3,8), photophobia and phonophobia (4, 6) . The recovery rate of the first and second admission was respectively 59.26% (16/27), 51.85% , the total effective rate was 76.92%, 55.56%. The total efficiency difference between the first and second hospitalization was statistically significant. 11 cases are definitely diagnosed as Meniere’s disease (4), cochlear migraine (6), paroxysmal vestibular disorder(1).
Conclusions: RLFSNHL more often attack young women and is effectively treated. However, with the increase of the number of onset, the therapeutic effect gradually decreases. RLFSNHL might be relative with Meniere’s disease, cochlear migraine and other diseases which involve a similar pathological mechanism.
PP2-143 - Cobalt-induced ototoxicity from metal-on-metal hip prostheses: preliminary results
27. Others
Laura Leyssens
1
Bart Vinck2, Catherine Van Der Straeten3, Ingeborg Dhooge4, Floris Wuyts5, Leen Maes6
1 University of Ghent, Department of Speech, Language and Hearing Sciences, Belgium
2 University of Ghent, Department of Speech, Language and Hearing Sciences, Belgium // University of Pretoria, Department of Speech-Language Pathology and Audiology, South Africa
3 Imperial College London, Department of Surgery and Cancer, United Kingdom // Faculty of Medicine and Health Sciences, University of Ghent, Belgium
4 University of Ghent, Department of Oto-rhino-laryngology, Belgium
5 Antwerp University Research center for Equilibrium and Aerospace (AUREA), Belgium // University of Antwerp, Department of Biomedical Physics, Belgium
6 University of Ghent, Department of Speech, Language and Hearing Sciences, Belgium // University Hospital of Ghent, Clinical Audiology Department, Belgium
Purpose: This study aims to evaluate the potential cochleotoxic and vestibulotoxic effect of cobalt (Co) ions released from metal-on-metal (MoM) hip prostheses.
Methods: 10* patients with a MoM implant and 10* age- and gender-matched control subjects participated in the study. Each participant was subjected to an extensive auditory and vestibular test battery and a blood sample collection, to determine the blood Co concentration. Statistical comparison of both groups was performed using a linear mixed model. * Data collection is ongoing; additional data will be supplemented to the existing pool.
Results: The patients exhibited a significantly higher blood Co concentration. Within the auditory test battery, pure tone audiometry showed a non-significant trend of higher thresholds in the patient group. The Distortion Product Otoacoustic Emission (DPOAE) signal amplitude at 4 and 8 kHz was significantly lower in the patient versus control group, and a similar but non-significant trend was observed for the Transient Evoked OAEs (TEOAEs) at 4 kHz and the DPOAEs at 6 kHz. Within the vestibular test battery, the P1 latency of the cervical Vestibular Evoked Myogenic Potentials (cVEMP) was significantly longer and the caloric sum significantly lower in the patient group. The outcome parameters of the Auditory Brainstem Responses (ABR), rotatory test, video Head Impulse Test (vHIT) and ocular VEMP (oVEMP) did not reveal significant differences between groups.
Conclusions: Our preliminary results suggest that high-frequency audiometric thresholds and DPOAE signal amplitudes, and the caloric sum may be the most sensitive parameters to detect cobalt-induced ototoxicity. This largely corresponds to previous findings regarding drug-related ototoxicity.
PP2-144 - Description of otoneurological findings in peripuberal females
27. Others
ANDREA XIMENA VARELA
1
MELISSA CASTILLO-BUSTAMANTE1, ANDREA RICARDO1, ANA CAROLINA BINETTI1
1 Buenos Aires British Hospital,Department of Otorhinolaryngology, Argentina
Purpose: To describe clinical and complementary studies in peripuberal females with otoneurological symptoms.
Methods: A case series was performed by a review of medical records of patients with otoneurological symptoms at Buenos Aires British Hospital , Argentina.
Results: This study included fourteen female patients, mean age was 13.1 ± 2 (9-16). Menarche mean age was 10.9 ±0.8. No statistically significant associations were found between comorbidities such as middle ear diseases, hypothyroidism, retinoblastoma and benign paroxysmal vertigo of childhood. Migraine was found as a significant comorbidity (p=0.002). Vertigo (79%) and headache (57%) were described as the most frequent consultation symptoms, only 21% of patients presented aural fullness. Only three patients presented otoneurological symptoms before menarche and seven women within 2 years after menarche. Audiometric tests (79%) and C-VEMP results (50%) were normal. No statistically significant differences were found between abnormal and normal videonystagmographies (64%); and pathological and non-pathological Video head impulse results (85%). Initial electrocochleography mean was 39 ±13.6 and eight months follow up mean was 25.2 ± 12.2. A significative decrease was observed eight months later (p=0.003) after treatment with betahistine in 80% of patients. Earlier Menarche age had a positive correlation with higher electrocochleography results (p=0.001).
Conclusions: Female teenagers presented vertigo and headache as the most frequent consultation symptoms. Migraine was observed as a significative comorbidity. Electrocochleography improvement was significative in patients after eight months follow-up. Earlier menarche age had a positive correlation with electrocochleography values.
PP2-145 - Direct Observational Procedural Skills in Otolaryngology Training
27. Others
CUNEYT KARA1
ERDEM MENGİ1, FUNDA TUMKAYA1, BULENT TOPUZ1,
FAZIL ARDIC
1
1 Pamukkale University, department of Otolaryngology, Turkey
Purpose: There are a lot of procedures like wax removal, microscopic ear examination, Dix-Halpike and Epley repositioning maneuvers that a resident have to learn perfectly in the first year of training. It is important to be sure about the skills of the residents before they examine a patients independently. The aim of this study is implantation of an assessment method, Direct observation of procedural skills (DOPS), during the training process of ENT residency.
Methods: A prospective educational research was planned. In the quantitative assessment, the “construct validity” of the assessment tool were examined. In the qualitative assessment, the trainees and trainers’ experiences about the contribution of DOPS in training process were investigated.
Results: A total of 55 DOPS forms were filled in. The mean observation time was 7.14±4.83 (max:20-min:1) minutes and the mean feedback time was 2.11±2.01 (max:10,min:0. ) minutes. A statistical difference was detected between the first year trainees and others, while no statistically difference between the thirth, fourth and fifth year trainees. A statistically significant positive correlation was found between the seniority years and the mean scores. According to qualitative assessment results, the trainees stated that they realized their some deficiencies, and it contributed positively to their residency training.
Conclusions: DOPS is a useful, valid and fair tool in assessing otolaryngology traniess. The data obtained from the DOPS forms can be used as an evidence to demonstrate the success of the training clinic and to evaluate the training program
PP2-146 - Distorted own-body representations and out-of-body experience in 350 patients with dizziness
27. Others
Christophe Lopez
1
Maya Elzière2
1 CNRS and Aix-Marseille University, LNSC, Marseille, France
2 Hôpital Européen, Centre des Vertiges, Marseille, France
Purpose: How vestibular disorders affect own-body and self representations has been overlooked, despite descriptions of depersonalisation-derealisation and cases of out-of-body experiences (OBE, the feeling that the self is located outside of the body) in patients with dizziness. This was explored in a large-scale observational, prospective study.
Methods: We measured the occurrence and severity of distorted own-body representations and OBE in the largest sample of patients with dizziness to date (n=350) compared to a group of age- and gender-matched healthy controls (n=350), using otoneurological examination, the Cambridge Depersonalization Scale, Hospital Anxiety and Depression Scale, and the Palmer’s questionnaire for OBE.
Results: Distorted own-body and self representations were more frequent and severe in patients with dizziness: 12% of the patients experienced their limbs have temporarily become larger or smaller, 37% reported abnormal sense of agency, 35% reported disownership for the body. We show a significantly higher occurrence of full-blown OBE in patients (14%) than controls (5%). Most of the patients experienced OBE only after they started having dizziness, and OBE was mainly related to peripheral vestibular disorders, never to bilateral vestibular failure. We identify depersonalization-derealization, depression and anxiety as the main predictors of OBE, as well as a contribution of migraine.
Conclusions: We propose that OBE may arise from a combination of perceptual incoherence evoked by the vestibular dysfunction, with psychological factors (depersonalization-derealization, depression and anxiety) and neurological factors (migraine). This study should help understand the complex symptomatology of patients with dizziness, who present with alterations of the most fundamental aspects of their self.
PP2-147 - Dizziness related to patulous eustachian tube
27. Others
Shigeto Ohta
1
Masafumi Sakagami1
1 Department of Otolaryngology-Head and Neck Surgery, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
Purpose: In 1989, Robinson et al. reported that 9 out of 13 patients with patulous eustachian tube (PET) had vestibular symptoms which improved on treatment of the PET. However, its pathogenesis remains unclear. The purpose of this study was to examine the characteristics of vestibular symptoms and function of patients with PET.
Methods: The study included 181 patients with PET. The diagnosis of PET was based on the criteria proposed by the Japan Otological Society (2016). The vestibular symptoms of all patients were recorded using a questionnaire. Furthermore, we conducted caloric test (43 patients), Schellong test (43 patients), and cervical vestibular evoked myogenic potential (cVEMP) test (27 ears of 20 patients) for patients with PET and dizziness.
Results: Vestibular symptoms were recorded in 79 of the 181 patients (44%) with PET. Seventy of the 79 patients (89%) with vestibular symptoms complained of mild dizziness and/or brief lightheadedness on standing up. Only 9 of the 79 patients (11%) experienced spinning. Canal paresis was observed in 2 of 43 patients (5%). Schellong test showed abnormal findings in 23 of 43 patients (53%). On the cVEMP test, the acoustic stimulus frequency at the largest amplitudes shifted to higher frequencies in 23 of 27 ears (85%).
Conclusions: The results indicate that 44% of the patients with PET had dizziness. The pathogenesis of dizziness related to PET is considered to be orthostatic dysregulation and/or otolith dysfunction.
PP2-148 - EEG Correlates of Postural Control and Balance
27. Others
Onur Guven1
Amy Edwards1,
Richard Ibitoye1, Patricia Castro1, Michael Furman1, Qadeer Arshad1, Adolfo Bronstein1
1 Neuro-otology Unit, Division of Brain Sciences, Imperial College London, Charing Cross Hospital, London, UK
Purpose: Non-visual afferent cortical contributions to postural control remain unclear. Parietal areas have been implicated however localisation during balance tasks is limited with neuroimaging. Here, we use EEG to investigate cortical activity during continuous balance at single electrode positions.
Methods: Experiment I) we investigate the impact of task difficulty upon alpha (8-12Hz) and theta (4-8Hz) bands in EEG - 24 healthy, right-handed adults performed seated (SITTING) and balance tasks (FLOOR, FOAM, R FOOT FLOOR, R FOOT FOAM) with eyes closed. Task difficulty was measured and increased in the order above. C3, Cz, C4, P3, P4 spectral power was analysed.
Results: Significant differences in theta power were demonstrated between hemispheres: C3-C4, Cz-C4, Cz-P4. There was a trend towards theta power reduction during active tasks, greater in the right hemisphere. Alpha power negatively correlated with task difficulty, in C3, C4, P3, P4, again greater in right vs left areas.
Experiment II) we recorded EEGs in sitting and standing in 8 healthy young adults, 8 healthy older adults and 4 older adults with dizziness, not explained by established diagnoses (perhaps due to small vessel disease). No major differences between Young and Old were found but dizzy patients had more pronounced reductions in alpha/theta activity.
Conclusions: We show hemispheric asymmetry in cortical activity during continuous balance. Reductions in alpha/theta power were greater in right-sided areas, suggesting a role for the non-dominant hemisphere in monitoring postural control. Increased reduction in alpha/theta power on standing in the dizzy patients suggests abnormal cortico-subcortical interaction but larger patient samples are required.
PP2-149 - Etiologic evaluation and risk factor profile of childhood hearing loss
27. Others
Maoli Duan
1
Kai Niu1, Inger Ulén1
1 Karolinska Institutet, Karolinska University Hospital, Otolaryngology Head and Neck Surgery, Sweden
Purpose: The goal was to clarify the prevalence and etiologic causes of childhood hearing loss (HL) in Swedish children and to evaluate the JCIH risk factor exposure in both bilateral hearing loss and unilateral hearing loss.
Methods: Subjects consisted of 296 infants suspected of hearing loss referred to a tertiary university hospital for further diagnosis and treatment. They belonged to the birth cohort spanning the years 2009-2013 in Stockholm County. The clinical data were collected from the electronic medical records of the Karolinska University Hospital. Age at reference, degree and type of HL were recorded. Risk factors and etiology of bilateral hearing loss (BHL) and unilateral hearing loss (UHL) were analyzed separately.
Results: 296 infants were confirmed with HL, and the prevalence of childhood HL was 2.0/ 1000 livebirths, of which BHL was present in 0.15%, while another 0.05% revealed UHL. Of the infants with BHL, familial history and neonatal indictor were the two most commonly discovered risk factors (26.7%, respectively), followed by syndrome related risk in 15.0% and craniofacial anomaly in 6.3%. Mean while, craniofacial anomaly was the most commonly exposed risk in children with UHL (48.9%), followed by familial history, which was found in 21.3% of children with UHL.
Conclusions: Pediatric hearing loss can be attributed to a variety of sources with an etiology identifiable in 47% of the patient with UHL and 42% of them with BHL while ear malformations were more commonly in infants with UHL. High congenital CMV infection (cCMV) rates were identified in this population.
PP2-150 - Influence of vestibular stimulation on executive functions
27. Others
Corina G. Schöne
1
Fred W. Mast1
1 Department of Psychology, University of Bern, Switzerland; Center of Cognition, Learning and Memory, University of Bern, Switzerland
Purpose: There is growing evidence that patients with peripheral vestibular loss show impairments in non-spatial cognitive domains like executive functioning. However, it is unclear which executive components are affected by vestibular loss and whether there is a causal link between vestibular loss and impaired executive functions. Therefore, the aim of this experiment was to investigate the effect of induced mild vestibular impairment in healthy participants on performance in tasks assessing executive functions.
Methods: Fifty-four participants solved executive tasks twice, before and during simultaneous bilateral bipolar galvanic vestibular stimulation (GVS). Suprathreshold GVS (inducing mild vestibular impairment), subthreshold GVS or sham GVS were applied. Core components of executive functions (working memory, inhibition, cognitive flexibility) were measured with two executive tasks (n-back task, Stroop task).
Results: Results indicate impaired performance in the working memory task during suprathreshold stimulation when compared to the groups receiving subthreshold or sham GVS. Performance in inhibition and cognitive flexibility showed no differences between groups. These results suggest that artificially induced mild vestibular impairment in healthy participants can lead to selective impairments in executive functions.
Conclusions: To investigate the causal influence of vestibular stimulation on the performance in executive tasks in healthy participants helps to explain executive deficits in patients with vestibular loss. Since executive functions are a composite of several distinct functions, it is important to more specifically determine the executive components which are affected by vestibular impairment. This can help to screen patients with vestibular loss, and ultimately provide cognitive training methods that are tailored to their pattern of performance.
PP2-151 - Influence of vestibular stimulation on phantom limb pain after supracondylar amputation
27. Others
Kathrine Jáuregui-Renaud
1
Catalina Aranda-Moreno1, Jaime Reyes-Espinosa2, Angelina Andrade -Galicia3, Ana E. Bastida-Segura4, Lourdes G. González Carrazco5
1 Unidad de Investigación Médica en Otoneurología. Instituto Mexicano del Seguro Social.
2 Hospital General de Zona 1”A”, Cd. de México. Instituto Mexicano del Seguro Social.
3 Unidad de Medicina Familiar 70, Estado de México. Instituto Mexicano del Seguro Social.
4 Hospital General de Zona 47, Cd. de México. Instituto Mexicano del Seguro Social.
5 Hospital General de Zona 8, Cd. de México. Instituto Mexicano del Seguro Social.
Purpose: In patients with unilateral supracondylar amputation of a lower limb, secondary to type 2 diabetes mellitus, to assess the influence of non-physiological vestibular stimulation (either angular or linear) on the intensity of phantom limb pain and symptoms of depersonalization/ derealization.
Methods: Thirty patients accepted to participate. They had phantom limb pain after at least 3 months of unilateral supracondylar amputation, without surgical complications. First, neuro-otology evaluation and assessment of symptoms of common mental disorders were performed. Then, using a cross-over design, in 2 separate sessions with one week in between, vestibular stimulation was delivered by right or left calorics (30°C or 44°C) or centrifugation (300/s, 3.5 cm). Before and after each vestibular stimulus, the intensity of pain and depersonalization/ derealization symptoms were appraised.
Results: In those who experienced phantom pain at the moment of vestibular stimulation, pain decreased in up to 91% of the patients after either right or left unilateral caloric stimulation (30°C or 44°C) or centrifugation, along with decrease of depersonalization/ derealization symptoms (p<0.005). In some patients, pain decrease persisted even one day after vestibular stimulation. Multivariate analysis showed no influence of the report of symptoms of common mental disorders on pain intensity.
Conclusions: Non-physiological vestibular stimulation, either angular or linear, may have an influence on phantom limb pain. We propose that this effect could be related to an update of the immediate experience of the body.
PP2-152 - Interaction between Vestibulo Ocular Reflex and Optokinetic Nystagmus in virtual reality worlds
27. Others
Dario Geisinger1
Keren Hayun2, Ari Zivotofsky2, Hamlet Suarez3,
Carlos R Gordon
4
1 Sackler Faculty of Medicine, Tel Aviv University, Israel
2 The Leslie and Susan Gonda (Goldschmied) Multidisciplinary Brain Research Center, Bar-Ilan University, Ramat Gan, Israel
3 Laboratorio de Otoneurologia, Montevideo, Uruguay
4 Department of Neurology, Meir Medical Center, Kfar Saba and Sackler Faculty of Medicine, Tel Aviv University, Israel
Purpose: We studied the optokinetic nystagmus (OKN) with an optokinetic stimulation (OKs) presented on virtual reality goggles were the stimulus velocity (from the subject’s perspective) remaines unchanged. We explored the eye movements and the perception of the OKs velocity while the head moved from side to side. If the OKN is purely dependent on the OKs, head movements should affect neither perception nor eye movements and we ought to see a classic OKN.
Methods: 10 healthy subjects (mean age 22.5, std 2.4) wore an eyetracking system (ICS, Otometrics) and over it a virtual reality viewer with a phone inside to display the optokinetic stimulation. Pace of head movements was set by a metronome (0.5Hz) and subjects were instructed to move the head from side to side (around 90 degree total movement) in a smooth and velocity-constant movement.
Results: Subjects report a change in velocity depending on whether the head moves in the same direction as the stimulation or the opposite direction. The number of the fast phase of the OKN with the same stimulus and opposite head movements, was significantly different for both OKs Left to Right and OKs Right to Left.
Conclusions: As opposed to a purely OKN response to an OKs, we see a differential eye movement dependent upon head rotation direction. The perceptual differences of OKs velocity presented in virtual reality while the head moves, could be attributed to different eye movements and these eye movements can be explained by simultaneous activation of the VOR and OKN.
PP2-153 - Mastoid Obliteration with Middle Temporal Artery and Inferior Musculoperiosteal Flaps
27. Others
Arthur Tan
1
Jia Hui Ng2, Edward Zhang2, Heng Wai Yuen2
1 Yong Loo Lin School of Medicine, National University of Singapore, Singapore
2 Changi General Hospital, Department of Otorhinolaryngology - Head & Neck Surgery, Singapore
Purpose: The aim of this study is to evaluate the surgical outcomes with the use of a combination of the middle temporal artery flap and the inferior musculoperiosteal flap for mastoid obliteration after canal wall down mastoidectomy.
Methods: A total of 55 patients who have undergone canal wall down mastoidectomy and mastoid obliteration with the middle temporal artery flap and the inferior musculoperiosteal flap were included. Surgical outcomes measured included time taken to mastoid cavity epithelisation, the creation of a dry mastoid cavity as measured by a previously developed semi-quantitative scale, and the rate of revision surgery needed.
Results: Patients were followed up for a median of 13 months. Median time to epithelisation of the mastoid cavity was 2 months (interquartile range 1-2). At 1 and 3 months, 36.2% and 69.0% of patients respectively had grade 0/1 cavities, with 1 or less episodes of mild otorrhea or sensation of wetness. 100% of patients achieved a grade 2 (more than 1 episode of otorrhea or the presence of granulation tissue that promptly resolved with simple treatment) or better cavity at 3 months. Throughout the entire follow up period, only 1 patient had a grade 3 cavity with uncontrolled infection and daily otorrhea secondary to an attic perforation that manifested at 6 months, requiring revision surgery.
Conclusions: The use of the middle temporal artery flap and the inferior musculoperiosteal flap for mastoid obliteration is an effective adjunct to achieving a safe, dry ear after canal wall down mastoidectomy.
PP2-154 - Metabolic syndrome among patients with different type of peripheral vestibular vertigo
27. Others
JONGBIN LEE
1
JONGWON LEE1, JONGJOONG CHOI1, MYEONGHEE KIM1, YEJI KIM1, JIHYUN KIM2
1 Department of Otorhinolaryngology, Konyang University, College of Medicine, South Korea
2 Department of Pediatric Endocrinology, Dongguk University, College of Medicine, South Korea
Purpose: No study has separately described and analyzed metabolic syndrome in patients with different types of peripheral vestibular vertigo. The present study investigated metabolic syndrome among patients with 4 different types of peripheral vertigo.
Methods: A total of 92 patients with 4 types of peripheral vertigo, namely, benign paroxysmal positional vertigo (BPPV, n=35), vestibular migraine (VM, n=24), Menière disease (MD, n=18), and vestibular neuronitis (VN, n=15), were included in the present study. Otological and neurootological examinations were carefully performed, and waist circumference, serum HDL level, serum triglyceride level, blood pressure and fasting glucose level were used to evaluate metabolic syndrome. In this study, metabolic syndrome was diagnosed according to standards suggested by the AHA/NHLBI ATP III 2005, and abdominal obesity (≥ 90 cm in men and ≥ 85 cm in women for Korean) was diagnosed according to standards set forth by the Korean Society for Study of Obesity.
Results: Patients were divided into 2 groups, according to the vestibular function: normal and abnormal vestibular function. There was no significant difference in the risk of metabolic syndrome between these 2 groups. However, for patients with the 4 different vertigo types, the prevalence of metabolic syndrome (VM=40.9%, VN=50%) was significantly higher in the patients with VM or VN than those with BPPV or MD (P<0.05).
Conclusions: Vestibular function is not significantly associated with the risk of metabolic syndrome. Metabolic syndrome is more common in patients with VM or VN than those with BPPV or MD.
PP2-155 - Predictive capability of an iPad based medical device for the diagnosis of vertigo and dizziness
27. Others
Katharina Feil1
Regina Feuerecker1, Nicolina Goldschagg1, Ralf Strobl2, Thomas Brandt3, Albrecht von Müller4, Eva Grill2,
Michael Strupp
1
1 Department of Neurology and German Center for Vertigo and Balance Disorders, Ludwig Maximilians University, Munich, Germany
2 German Center for Vertigo and Balance Disorders and Institute for Medical Information Processing, Biometrics and Epidemiology (IBE), Ludwig Maximilians University, Munich, Germany
3 German Center for Vertigo and Balance Disorders and Institute for Clinical Neurosciences, Ludwig Maximilians University, Munich, Germany
4 Parmenides Foundation, Kirchplatz 1, 82049 Munich/Pullach
Purpose: Making the correct diagnosis of patients presenting with vertigo and dizziness in clinical practice is often challenging. In this study, we analyzed the usage of the iPad-based program medx in the prediction of different diagnoses.
Methods: The data collection was done in the outpatient clinic of the German Center of Vertigo and Balance Disorders. The“gold standard diagnosis” was confirmed by a physician there. The medx diagnosis was based on an algorithm using all available clinical information. The accuracy of the system was defined as the number of correctly classified patients. Moreover, sensitivity, specificity as well as positive and negative predictive values for the most common diagnoses were reported.
Results: 610 patients (mean age58.1±16.3 years,51.2%female) were included. The accuracy for the most common diagnoses was between 82.1-96.6% with a sensitivity of 40-80.5% and a specificity of >80%. When analyzing the quality of medx in a multiclass-problem for the six most common clinical diagnoses the sensitivity, specificity, positive and negative predictive value were as follows: Bilateral vestibulopathy (81.6%,97.1%,71.1%,97.5%), Menière’s disease (77.8%,97.6%,87.%,95.3%), benign paroxysmal positional vertigo (61.7%, 98.3%, 86.6%, 93.4%), downbeat nystagmus syndrome (69.6%, 97.7%, 71.1%, 97.5%), vestibular migraine (34.7%,97.8%,76.1%, 88.3%) and phobic postural vertigo (80.5%,82,5%, 52.5%, 94.6%).
Conclusions: With the high specificity and high negative predictive value the medx system helps to rule out differential diagnoses and can therefore also lead to a cost reduction in health care system. However, in some disease the sensitivity was unexpectedly low. Therefore, this device can only be a complementary tool, in particular for non-experts in the field.
PP2-156 - Prevalence of and factors related to mild and substantial dizziness in older adults
27. Others
Ann-Sofi Kammerlind
1
Marie Ernsth Bravell2, Eleonor Fransson3
1 Region Jönköping County, Futurum, Sweden and Linköping University, Department of Medical and Health Sciences, Sweden
2 Jönköping University, Institute of Gerontology, Sweden
3 Jönköping University, Department of Natural Science and Biomedicine, Sweden and Karolinska Institutet, Institute of Environmental Medicine, Sweden
Purpose: The aim of the study was to determine the prevalence of and factors related to dizziness among community-dwelling older adults in Sweden.
Methods: A sample of 305 older persons between 75 and 90 years of age (mean age 81 years) were interviewed and examined. Subjects with dizziness answered the University of California Los Angeles Dizziness Questionnaire and questions about provoking movements. The groups with substantial, mild, or no dizziness were compared with regard to age, sex, diseases, drugs, blood pressure, physical activity, exercises, falls, fear of falling, quality of life, general health, mobility aids, and physical performance. In contrast to previous studies, the subjects with dizziness were divided into two groups, mild and substantial dizziness, according to the frequency and intensity of dizziness.
Results: In this sample, 79 subjects experienced substantial and 46 mild dizziness. Subjects with substantial dizziness were less physically active, reported more fear of falling, falls, depression/anxiety, diabetes, stroke/TIA, heart disease, a higher total number of drugs and antihypertensive drugs, lower quality of life and general health, and performed worse physically.
Conclusions: There are many and complex associations between dizziness and factors like falls, diseases, drugs, physical performance, and activity. For most of these factors, the associations are stronger in subjects with substantial dizziness compared with subjects with mild or no dizziness; therefore, it is relevant to differ between mild and substantial dizziness symptoms in research and clinical practice in the future.
PP2-157 - Recovery of Ocular and Cervical Vestibular Evoked Myogenic Potentials after Vertigo Attacks
27. Others
Zichen Chen1
Juan Hu1, Hua Wang1, Maoli Duan2, Min Xu1, Peng Han1, Ying Cheng1, Ying Gao1, Qing Zhang1
1 Department of Otorhinolaryngology- Head and Neck Surgery, Second Affiliated Hospital, Xi’an Jiaotong University School of Medicine, Xi’an, China
2 Department of Neurotology and Audiology, Karolinska University Hospital, Stockholm, Sweden
Purpose: This study reports the ocular vestibular evoked myogenic potential (oVEMP) and/or cervical vestibular evoked myogenic potential (cVEMP) recovery after peripheral vertigo attack. The study aimed at assessing the clinical value of oVEMP and cVEMP for monitoring the rehabilitation of vestibular function.
Methods: Six patients diagnosed with peripheral vertigo with no VEMP response on the affected side but exhibiting symptom alleviation and VEMP responses after therapies were enrolled. The restoration and parameters of their VEMP response were analyzed.
Results: After treatment, three patients with sudden sensorineural hearing loss showed VEMP recovery, including one on both oVEMP and cVEMP recovery, and the other two on oVEMP recovery only. One patient of Meniere’s disease showed cVEMP recovery, while the other Meniere’s disease patient showed oVEMP recovery. One patient of Herpes Zoster Oticus exhibited cVEMP recovery. All the patients presented normal VEMP parameters before and after treatment.
Conclusions: Combined oVEMP and cVEMP are objective tools to assess vestibular otolithic end organ function in the process of dynamic functional recovery in vestibular diseases.
PP2-158 - Sub-clinical symptoms of postural-perceptual dizziness are associated with general sensory avoidance
27. Others
Georgina Powell
1
Simon, K. Rushton1, Hannah Derry-Sumner2, Deepak Rajenderkumar2, Petroc Sumner1
1 School of Psychology, Cardiff University
2 Department of Audiology, University Hospital of Wales, Cardiff
Purpose: Persistent postural-perceptual dizziness (PPPD) is a condition where certain visual environments trigger vertigo and nausea. Our interest is whether symptoms of PPPD lie on a spectrum in the general population and how these symptoms relate to more general sensory processing.
Methods: We used the Situational Characteristics Questionnaire (SCQ) and the Visual Vertigo Analogue Scale (VVAS) to examine symptoms of PPPD in 219 undergraduate students. We related these measures to the sensory avoidance subscale of the Adult Sensory Profile (ASP).
Results: We found that PPPD symptoms were surprisingly common in this non-clinical sample, with 9% of participants within a clinically relevant range for the SCQ and 6% above a patient cohort average for the VVAS. Symptoms on both scales were associated with increased sensory avoidance across all modalities (e.g. touch, smell, audition) as measured by the ASP (R for SCQ = 0.34, R for VVAS = 0.45).
Conclusions: These results suggest that the visual-vestibular atypicalities characteristic of PPPD could generalise to other sensory modalities. Ongoing research is examining whether this relationship is influenced by psychophysical measures of sensory performance and psychiatric factors such as anxiety. We are also validating the results with members of the general population and a PPPD patient population.
PP2-159 - The central nervous system complications accompanied by Ramsay-Hunt syndrome
27. Others
Taro Inagaki
1
Shigeto Itani1, Yoichi Okayoshi1, Kyoko Shirai1, Ayumi Takano1, Yusuke Aihara1, Kiyoaki Tsukahara1
1 Tokyo Medical University, Department of Otorhinolaryngology Head and Neck Surgery, Japan
Purpose: Reactivation of the latent varicella zoster virus (VZV) in the geniculate ganglion of facial nerve causes Ramsay-Hunt syndrome (RHS). Three features of RHS are the facial palsy, inner ear disorder and auricular herpes zoster. RHS may hurt around cranial nerves and even the central nervous system (CNS).
Methods: The patient was 50-year-old female, and she had the breast cancer which was undergoing the chemotherapy in our hospital. She felt vertigo and nausea and was referred to our department.
Results: In gaze nystagmus test, the rightward nystagmus was found in all eye positions. And left auricle and parotid skin were reddish without left facial palsy. Next day, she complained the double vision and the left hearing loss, and the left auricular herpes zoster appeared without any other cranial nerve complication. Moreover, the right obliquely upward nystagmus was mixed with rightward nystagmus in gaze nystagmus test, and the skew deviation was found. Then the treatment to the VZV infection was started. Two days later, fortunately, the skew deviation disappeared and there was no finding in ENG test except the left canal paresis in caloric test. Next day, the facial palsy appeared, and she was diagnosed as RHS.
Conclusions: Skew deviation is an unusual ocular deviation, most commonly due to brainstem or cerebellar stroke. Reactivation of the VZV is easy to occur in the patients with decrease of immunity, and the geniculate ganglion of facial nerve is closed to brainstem and cerebellum. Therefore, we should be concerned about CNS complication in the patient with RHS.
PP2-160 - The ototoxic effect of cisplatin on vestibular hair cells in vitro
27. Others
Jingchun He
1
Shuna Li1, Jun Yang1
1 Shanghai Jiao Tong University/Xin Hua Hospital, ENT, China
Purpose: to investigate the ototoxic effect of cisplatin on vestibular hair cells of saccule and utricle in vestibular organ cultures.
Methods: The macula utriculi and macula sacculi of three- or four-day-old F344 rats was cultured and treated with various doses of cisplatin for 48 h. Vestibular hair cells were stained with immunouorescence and were observed under confocal microscope.
Results: The in vitro culture of vestibular hair cells in the control group grew well during the 48h culture and only an occasional loss of vestibular hair cells occurred. Cis-treated vestibular tissue showed loss of hair cells at low concentration (Cis10μM, Cis50μM, Cis100μM). The overall vestibular hair cell loss for Cis-treated macula utriculi and macula sacculi was 30 % at 10μM concentration, 80 % at 50μM, 50% at 100μM. However, at high concentrations of cisplatin(Cis 400μM and Cis1000μM), most hair cells were intact. In all groups of cisplatin, ANOVA showed that there are statistically.
Conclusions: In vitro culture, cisplatin is ototoxic to vestibular hair cells. However, cisplatin-induced ototoxicity to vestibule showed a non-dose-dependent manner. Vestibular air cells possess intrinsic resistance to high levels of extracellular cisplatin. We speculate that this may be related to intake mechanism of cisplatin and molecular autophagy mechanism.
PP2-161 - Vestibular Neuropathy in Auditory Neuropathy: Detected by Vestibular Evoked Myogenic Potentials
27. Others
Juan Hu
1
Zichen Chen1, Yuzhong Zhang1, Yong Xu2, Weijun Ma1, Yan Zhang1
1 Department of Otorhinolaryngology, Head and Neck Surgery,the 2nd Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
2 Department of Otorhinolaryngology, Head and Neck Surgery, Yanliang 141 Hospital, Xi’an, China.
Purpose: The aim of this study is to evaluate the lesion and the extent of vestibular involvement in patients with auditory neuropathy (AN) using the vestibular test battery of ocular vestibular evoked myogenic potential (oVEMP), cervical vestibular evoked myogenic potential (cVEMP) and Caloric test.
Methods: Sixteen patients (32 ears) of AN were enrolled as the case group, and fifty age- and sex- matched normal subjects (100 ears) enrolled as the control group. All of the subjects underwent air-conducted oVEMP and cVEMP tests in bilateral ears, and 14 of the AN patients underwent Caloric test. The results were compared between the two groups.
Results: Significant differences in VEMP abnormality were found between the AN group and the control group. In the AN group, the ratio of response was 31.25% in oVEMP test and 21.88% in cVEMP test, which was lower than that in the control group (93% and 97%, both P<0.01). The parameters of VEMP test, including amplitude, n1 latency, p1 latency, n1-p1 interpeak latency, also showed significant differences between the two groups. Of the 14 AN cases underwent Caloric test, 6 cases showed unilateral semicircular canal weakness and another 3 showed bilateral caloric weakness, with an abnormal rate of 64.28%.
Conclusions: This study is among first to use the combination of oVEMP, cVEMP and Caloric test to assess the status of vestibular function in AN. Most AN patients experienced disturbance of vestibular function. The test battery of VEMPs and Caloric testing may provide valuable information for detecting vestibular abnormalities in AN.
PP2-162 - Vestibular Symptoms and Function in Veterans with Post Traumatic Stress Disorder
27. Others
K Brewer1
MC Schubert2, Y Haber1, S Wood3, H Chandler4,
JM Serrador
1
1 War Related Illness & Injury Study Center, Dept of Veteran Affairs, USA & Rutgers Biomedical Health Sciences, USA
2 Johns Hopkins, USA
3 Azusa Pacific University, USA
4 War Related Illness & Injury Study Center, Dept of Veteran Affairs, USA
Purpose: Posttraumatic Stress Disorder (PTSD) is a complex condition that has a range of symptoms of which a commonly reported one is dizziness. Given the overlap of symptoms in veterans with PTSD and vestibular patients, the question arises if vestibular dysfunction may be under diagnosed in veterans with PTSD due to the overlap in symptoms.
Methods: In a study of 124 veterans (age 53.9±9.9 yrs) we assessed vestibular symptoms using the VSS, DHI and VDADL. We also measured vestibular function with vHITs and ocular torsion. PTSD status was determined via the PCL.
Results: 53% of the Veterans were classified as having PTSD. As was expected those with PTSD had a significantly greater incidence of severe dizziness (48% vs 13%) and higher scores on DHI (35±30 vs 11±20), VSS (14±11 vs 4±6), VDADL (65±37 vs 38±18) and lower balance confidence (75±23 vs 91±15), all P<0.001. However, they did not differ in ocular torsion or vHIT gain values. There was a correlation between Right Posterior Canal Gain and PCL score, with higher PCL scores correlated to reduced gain (R=-0.21, P=0.045). Surprisingly this was not true for the Left Posterior canal. There was also a strong correlation between PCL score and Balance Confidence (R=0.50, P<0.001).
Conclusions: These data demonstrate that veterans with PTSD report significant vestibular symptoms that impair their daily activity and are associated with reduced balance confidence. However, they did not demonstrate impairments in canal or otolith measures, expect for right posterior canal gain. Further work is necessary to determine causes of the symptoms.
PP2-163 - Voluntary eye closure disrupts the vestibulo-ocular response to head rotation in man and monkey
27. Others
Patrick Forbes
1
Omid Zobieri2, Emma Raat1, Jean-Sebastien Blouin3, Kathleen Cullen2, Johannes van der Steen1
1 Erasmus Medical Centre, Department of Neuroscience, the Netherlands
2 Johns Hopkins University, Department of Neuroscience, USA
3 University of British Columbia, School of Kinesiology, Canada
Purpose: Vestibulo-ocular reflexes (VOR) produce eye movements that minimize retinal image motion during head movement; though, it does not depend on visual input and functions in darkness. The effect of eye closure, however, which similarly eliminates vision, remains unclear. Authors report decreased/absent vestibular-evoked eye movements while others describe no change. Here, we performed experiments in man and monkey to investigate modulatory effects of eye closure on the VOR.
Methods: Human (N=26) and rhesus monkeys (N=2) were exposed to whole-body sinusoidal, step or pseudorandom rotations with eyes open and closed in darkness. Eye movements were recorded with scleral (human) or implanted (monkeys) search-coils.
Results: Across conditions, voluntary eye closure reduced VOR gains from ~0.8-1.0 to ~0.1-0.3 in humans. Gains decreased in all sinusoidal rotation directions (horizontal/vertical/torsional) during eye closure, with the largest relative decreases (~60-70%) in horizontal/vertical directions. Taping one eye shut during step rotations moderately decreased gains (~10-15%), suggesting that mechanical restriction or afferent feedback play minor roles in attenuation. In contrast, attempting to open the lids when both eyes were taped shut increased VOR gains 4-times relative to voluntary closure; suggesting VOR engagement is related to the motor command to open the eyes. Finally, parallel studies in humans and monkeys established a link between lid closure and VOR attenuation: during pseudorandom rotations, gain decreased rapidly (~60-70%), and in humans initiated with eye deviations starting 40-60ms prior to lid motion.
Conclusions: Our results show robust attenuation of the VOR during voluntary eye closure that is related to the motor command to close the lids.
PP2-164 - Walking to the Toilet in Impatient with Vertigo (5th report)-An Evaluation Using the DHI
27. Others
Akira Doi
1
Fumiyuki Goto2, Kozo Tamura1, Kenichi Kozakura1, Kensuke Uraguchi1, Yuka Hirata3, Yukari Nishimori3, Seiji Kobayashi4, Kazunori Nishizaki5
1 Kochi Health Sciences Center, Division of Otolarynology, Kochi, Japan
2 National Hospital Organization Tokyo Hospital, Department of Otolaryngology, Tokyo, Japan
3 Kochi Health Sciences Center, Clinical Laboratory, Kochi, Japan
4 Kochi Health Sciences Center, Rehabilitation Section, Kochi, Japan
5 Okayama university Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Otolaryngology-Head and Neck Surgery, Okayama, Japan
Purpose: Since the 25th Barany Society Meeting, we have been studying the Waliking to the toilet in patient with vertigo. Hypertension and ages of 65years or older were identified s toilet walk prolongation factors. In this study, we examined the relationship between hypertension and daily activity ratings determined using the Dizziness Handicap Inventry(DHI) questionnaire in patients with vertigo. Tendencies in the DHI ratings in daily activities were also examined.
Methods: The study population comprised 215 patients with vertigo who presented to the outpatient clinic of the of Kochi Health Sciences Center between January and March 2015. Items for investigation: The patients were divided into six groups according to the number of DHI questions responded with the answer “Yes”:”0”, “1-5”, “6-10”, “11-15”, “16-20”, and “21-25”. The proportion ofhypertensive patients and the distribution of physical(P), emotional(E), and functional(F) ratings in each group were determined.
Results: The population of hypertensive patients was high at 42.9% in the “21-25” group, with no significant differences found in the other groups. In the “11-15” group, the rating E accounted for a high percentage.
Conclusions: In the “21-25” group, hypertension had may also be an influential factor in their daily activities. In the other groups, hypertension had little influence in the daily activities. Blood pressure fluctuation and hemodynamic changes in the presence of vertigo were suggested to be the reasons for the influence of hypertension in their “toilet walk” during hospitalization for vertigo. In the “11-15” group, Psychological influence may have been more closely involved in the daily activities than hypertension.
PP2-165 - When on earth a patient with congenital nystagmus experiences oscillopsia? -A case report-
27. Others
Tomoyuki Okada
1
Kotaro Kotaro Arai1, Kosuke Kawashima1, Manabu Nakamura1, Fumihiro Mochizuki1, Yasuhiro Miyamoto1, Tadashi Nakamura1, Izumi Koizuka1
1 St Marianna University School of Medicine, Department of Otolaryngology, Japan
Purpose: Patients with congenital nystagmus (CN) usually do not experience oscillopsia. There are some suggestions about this lack of oscillopsia in CN, but some patients experience oscillopsia, actually. Our purpose is to know why our CN patient experienced oscillopsia and to prove whether or not we could record strange eye movements on each eye recording when he experienced oscillopsia.
Our CN patient as follows: A PAN type patient wearing glasses who was 30-year-old software engineer man, had lots of complaints (dizziness, blurred vision and/or oscillopsia), in particular, during computing, whom he got behind in his daily living in the end, was referred and visited to our clinic.
Methods: We routinely investigate CN by using a goggle with bilateral infra-red CCD cameras, which can record each eye movement simultaneously. Eye movements are recorded under gazing onto the imaginary target, like examiner’s nose, for ten seconds, in front of them at the primary position. We analyse each eye movement by use of a software named Image J.
Results: At our follow-up clinic, when he wore glasses, he had lots of complaints and the analysed eye movements indicated his each eye had own eye movements, like chameleon’s eye movements. After asking him not to wear glasses, and allowing him to wear contact lenses, he was gradually getting better of his symptoms and he had nothing to complain. The analysed eye movements indicated similar oscillations on both eyes.
Conclusions: We thought his workaholism and wearing glasses could influence his visual surroundings and eye movements. He experienced oscillopsia, finally.
