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Department of Otolaryngology Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, TN 37232
Department of Hearing and Speech Sciences, Vanderbilt University Medical Center, Nashville, TN 37232
A BS TRACT
Article history:
Purpose: The ocular vestibular evoked myogenic potential (oVEMP) represents the sound-
induced activation of extraocular muscles and is believed to originate from the utricle and
superior vestibular nerve. Isolated unilateral oVEMP abnormalities with otherwise normal
balance function test (BFT) results have not yet been characterized in a large patient series,
and their clinical significance remains unclear.
Materials and Methods: Retrospective review of adult patients with vestibular complaints at
a tertiary academic neurotologic referral center was performed. Patients with isolated
unilateral oVEMP abnormalities were identified. The prevalence of vestibular symptoms
and results of the Dizziness Handicap Inventory (DHI) and Hospital Anxiety and Depression
Scale (HADS) were compared between these patients and those with normal BFT results.
Results: Thirty-one adult patients with isolated unilateral oVEMP abnormalities were
identified (71% female, mean age 48 14 years). Presenting complaints included vertigo in
53%, non-vertiginous dizziness in 68%, postural instability in 52%, and swaying/rocking
sensation in 13%. Significant differences were observed in the percentage of patients with
postural instability (p = 0.046) and swaying/rocking sensation (p = 0.04) when comparing
the abnormal oVEMP group to patients with a normal BFT battery. No differences were
observed when comparing other symptoms, age, gender, diagnoses, and DHI/HADS scores
between groups.
Conclusion: This is the largest series to date reporting on patients with isolated unilateral
oVEMP abnormalities. Our results suggest this population may demonstrate an increased
prevalence of postural instability and swaying/rocking sensation. Other measures of
postural stability may further characterize the vestibular impairments associated with
isolated unilateral utricular dysfunction.
2013 Elsevier Inc. All rights reserved.
Publication statement: Data from this manuscript will be presented at the 2013 Combined Otolaryngology Spring Meetings, Orlando,
Florida. The material in this manuscript is not under consideration for publication in another journal. IRB approval number: 120131.
Corresponding author. Department of Otolaryngology Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, TN
37232. Tel.: + 1 615 322 6180.
E-mail address: stanley.pelosi@vanderbilt.edu (S. Pelosi).
0196-0709/$ see front matter 2013 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.amjoto.2013.04.008
1.
Introduction
The otolith organs are sensitive to changes in linear acceleration and head tilt and are thought to play a role in postural
stability. The otoliths also have sound sensitivity, and their
activation in response to acoustic stimulation is the basis for
the vestibular evoked myogenic potential (VEMP). The cervical
VEMP (cVEMP) represents the sound-evoked attenuation of
the tonically activated sternocleidomastoid muscle (SCM)
following a high-intensity acoustic stimulus. The response is
thought to originate from the saccule [1], and it assesses the
vestibulocollic reflex (VCR), which coordinates neck muscle
contraction for head stabilization in response to movement.
Ocular VEMP (oVEMP) testing is another method of using
myogenic potentials to assess the vestibular system. The
oVEMP represents the sound-induced activation of extraocular muscles and is best recorded from beneath the contralateral eye (i.e. contralateral to the stimulated ear). This response
assesses the integrity of the vestibulo-ocular reflex (VOR),
which is mediated by the medial longitudinal fasciculus.
VEMPs have an evolving role in the diagnosis of several
vestibular disorders. Decreased or unilaterally absent cVEMP
responses may be seen in Mnire's disease, vestibular neuritis,
and vestibular schwannomas, while unilateral increased amplitudes and abnormally reduced response thresholds may be
seen in superior semicircular canal dehiscence syndrome [2].
oVEMPs can also be altered in various peripheral vestibular
disorders [2], although these responses are frequently dissociated from cVEMP abnormalities in patients with peripheral
vestibular dysfunction [36]. Both cVEMP and oVEMP responses
may be reduced or eliminated by advanced age [7].
The origin of the oVEMP has been a topic of considerable
discussion. The most recent evidence suggests that the
oVEMP in response to air-conducted sound and recorded
with strategically placed infraorbital electrodes is generated
from the utricle and superior vestibular nerve [8]. Several
anatomic studies have demonstrated that air conduction
stimuli can activate utricular afferents [9,10], and the utricle
has been shown to possess stronger projections to the
extraocular muscles than the saccule [11,12]. Additionally,
abnormalities in the static subjective visual horizontal, a
psychophysical test believed to assess utricular function, have
been found to correlate with oVEMP abnormalities [13].
Since caloric testing evaluates the function of the lateral
semicircular canal and superior vestibular nerve, while oVEMP
tests the status of the utricle and superior nerve, the presence
of a unilateral oVEMP abnormality and normal caloric responses suggests dysfunction of the utricle alone. Isolated
oVEMP abnormalities with otherwise normal balance function
test results have not yet been well-characterized, and their
clinical significance remains unclear.
We wish to further characterize the clinical presentation of
patients who are found to have isolated unilateral oVEMP
abnormalities on vestibular function testing. Other reports
have examined isolated unilateral utricle dysfunction as
tested by abnormalities in the SVV during eccentric rotation
[14,15], but to date no large series have specifically reported on
clinical symptoms in patients with isolated unilateral oVEMP
abnormalities. Our hypothesis was that because of compen-
491
2.
Methods
492
and each tracing was replicated at least one time. The amplitude
of the P13-N23 response was then measured, and an amplitude
asymmetry greater than 47% between ears was considered to
be abnormal [20]. Background EMG activity of the SCM muscle
was not recorded, although an optimal positioning technique
for eliciting consistent cVEMP responses was used [21].
oVEMP testing was performed with active electrodes
placed in the infraorbital region 1 cm below each eye.
Reference electrodes were placed approximately 3 cm beneath the active electrode, and a ground electrode was placed
on the forehead. The patients were tested in a semirecumbent position. During signal averaging patients were
asked to stare at a target on the ceiling that forced them to
elevate their gaze ~ 30 degrees, and to maintain this gaze for
2030 seconds. The same acoustic stimulus used to record the
cVEMP was also employed for oVEMP testing. The resulting
myoelectrical activity was amplified by 100,000, bandpass
filtered between 10 and 1500 Hz, and signal-averaged over 100
milliseconds. Each oVEMP tracing represented the average of
~ 150 individual samples. A significant oVEMP N10-P15
amplitude asymmetry was defined as > 34% [19].
The Dizziness Handicap Inventory (DHI) was completed by
all patients using a paper-pencil administration format to
assess self-reported disability/handicap. The DHI asks a
patient to answer yes (4 points), sometimes (2 points),
or no (0 points) to a list of 25 questions relating how
dizziness symptoms affect their daily lives [22]. Also performed was the Hospital Anxiety and Depression Scale
(HADS), a questionnaire with seven items assessing the extent
of depression and seven which relate to anxiety. Each item on
the questionnaire is scored 03, with a score between 11 and
21 indicating significant levels of anxiety or depression [23].
3.
Results
Table 1 Clinical characteristics of dizzy patients with abnormal oVEMP test results v. normal vestibular function tests
results.
Patient group
Gender
Age, years (mean SD)
Vestibular symptoms
Vertigo
Non-vertiginous dizziness
Postural instability
Swaying/rocking sensation
Otologic symptoms
Tinnitus
Diagnoses
Migraine
BPV
Menieres disease
Viral labyrinthitis
Mal de debarquement
No diagnosis rendered
DHI score (mean SD)
HADS score (mean SD)
Depression
Anxiety
p value
71% F
48 14
77% F
49 16
55%
68%
52%
13%
81%
67%
63%
60%
27%
63%
50%
35%
13%
13%
6%
3%
29%
32 23
23%
13%
7%
3%
53%
36 19
54
12% abnormal
84
36% abnormal
(n = 25)
54
12% abnormal
75
24% abnormal
(n = 25)
493
Table 2 Clinical characteristics of patients with reduced oVEMP v. absent oVEMP responses.
Patient group
Gender
Age, years (mean SD)
Vestibular symptoms
Vertigo
Non-vertiginous dizziness
Postural instability
Swaying/rocking sensation
Otologic symptoms
Tinnitus
Diagnoses
Migraine
BPV
Menieres disease
DHI score (mean SD)
HADS score (mean SD)
Depression
Anxiety
Reduced oVEMP
(n = 13)
P value
85% F
49 12
61% F
47 16
54%
85%
46%
23%
77%
77%
56%
56%
56%
6%
83%
61%
0.93
0.09
0.61
0.15
0.66
0.35
(chi-square
(chi-square
(chi-square
(chi-square
(chi-square
(chi-square
46%
15%
36 22
28%
22%
11%
29 25
0.29
0.07
0.73
0.44
(chi-square = 1.11, df = 1)
(chi-square = 3.32, df = 1)
(chi-square = 0.12, df = 1)
(t-test, t = 0.78, df = 29)
44
9% abnormal
84
36% abnormal
(n = 11)
64
14% abnormal
84
36% abnormal
(n = 14)
0.38
0.69
0.82
0.97
4.
Absent oVEMP
(n = 18)
Discussion
=
=
=
=
=
=
0.01, df
2.92, df
0.27, df
2.06, df
0.20, df
0.86, df
=
=
=
=
=
=
1)
1)
1)
1)
1)
1)
494
5.
Conclusion
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