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Background: Although various medical remedies have been attempted to alleviate the symptoms of Meniere's disease (MD), the risk-benefit ratios of these various treatments remain debatable., Objective: We investigated the efficacy of sound stimulation of 100 Hz for treating vestibular dysfunction in patients with Meniere's disease (MD)., Materials and Methods: Patients with definitive MD with intractable vestibular symptoms and endolymphatic hydrops (EH) in the inner ear were evaluated. The experimental group received sound stimulation of 75 dB at a frequency of 100 Hz for 5 min, and the control group received sound stimulation of 75 dB at a frequency of 250 Hz for 5 min. Cervical vestibular-evoked myogenic potentials (cVEMPs) were measured before and after each sound stimulation, and the results of the clinical tests were compared between the two patient groups., Results: Significant increases in cVEMP amplitudes were observed after sound stimulation of 100 Hz in ears with vestibular endolymphatic hydrops, although no such improvement was observed in the control group., Conclusion: Sound stimulation of 75 dB at a frequency of 100 Hz leads to improvement in cVEMP amplitude in patients with definitive MD. Adequate sound stimulation might be a new method for treating vestibular dysfunction associated with MD.

Introduction: Spatial navigation, the ability to move through one's environment, is a complex skill utilized in everyday life. The effects of specific vestibular end-organ deficits and hearing impairments on spatial navigation have received little to no attention. We hypothesized that hearing impairment adversely affects spatial navigation and that bimodal impairments (vestibular and hearing) further impair navigation ability., Methods: Data from 182 participants in the Baltimore Longitudinal Study of Aging who had interpretable results for the video head impulse test (vHIT), cervical vestibular evoked myogenic potentials (cVEMP) and ocular vestibular evoked myogenic potentials (oVEMP), audiometric testing, and the triangle completion test (TCT) were retrospectively analyzed. Multiple linear regression, controlling for age, sex, and cognition, was employed to identify predictors of TCT performance in terms of end-point error, angle deviation, and distance walked., Results: oVEMP abnormalities were associated with larger end-point error (p = 0.008) and larger angle deviation (p = 0.002) but were not associated with distance walked (p = 0.392). Abnormalities on cVEMP testing and vHIT were not associated with distance walked (p = 0.835, p = 0.300), end-point error (p = 0.256, p = 0.808), or angle deviation (p = 0.192, p = 0.966). Compared with normal-hearing adults, hearing-impaired adults walked a shorter distance during the TCT (p = 0.049) but had a similar end-point error (p = 0.302) and angle deviation (p = 0.466). There was no interaction between vestibular and hearing function for predicting spatial navigation ability., Conclusion: In this cohort analysis, utricular dysfunction and hearing impairment were associated with poorer spatial navigation performance. We postulate that hearing impairment negatively affects one's ability to use real-time, intrinsic auditory cues and/or prior experience to guide navigation., (© 2024 S. Karger AG, Basel.)

Objective: The purpose of this study was to investigate the effects of excessive cerebrospinal fluid (CSF) retention on the peripheral vestibular function and the inner ear fluid in patients with idiopathic normal pressure hydrocephalus (iNPH)., Methods: In 25 patients with iNPH (14 females, age 65-88 years), cervical vestibular evoked myogenic potential (cVEMP) was measured before the spinal tap test. The asymmetry ratios (ARs) and tuning properties in 500 Hz and 1,000 Hz short-tone burst stimuli of cVEMP were evaluated. Furthermore, cVEMP was measured in an age-matched control group of 12 non-iNPH patients., Results: Seven (28%) iNPH patients exhibited a cVEMP asymmetry (AR > 33%). cVEMP tuning was significantly shifted to a higher frequency in the iNPH group than in the age-matched control group., Conclusions: One-fourth of patients with iNPH had obvious saccular dysfunction. A high rate of a shift in cVEMP tuning in the iNPH group indicated that excessive CSF accumulation propagated to the endolymph and perilymph., Significance: Saccular dysfunction might be one of the possible causes of imbalance in iNPH, and the shift in cVEMP tuning may be a determining factor in the diagnosis and treatment strategy., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2021 International Federation of Clinical Neurophysiology. Published by Elsevier B.V. All rights reserved.)

Background: Studies of saccular and utricular function in patients with obstructive sleep apnea (OSA) are rare. We noticed that some OSA patients also had positive results in vestibular function tests, and this inspired our interest in exploring the vestibular function patterns of OSA patients., Objectives: To investigate otolithic organ function in severe OSA patients who lack vestibular symptoms and systemic disease., Material and Methods: 32 patients (64 ears) with severe OSA and 22 healthy controls (44 ears) were enrolled. The ocular and cervical vestibular-evoked myogenic potentials (oVEMP and cVEMP) and the caloric test were recorded and analyzed., Results: The response rates of oVEMP (73.4%) and cVEMP (82.8%) in patients with severe OSA were significantly lower than those in controls. In oVEMP, elevated thresholds ( p  = .002), decreased n1-p1 amplitudes ( p  < .001), prolonged n1 latencies ( p  < .001) were observed. In cVEMP, the elevation of thresholds ( p  < .001), decrease in p1-n1 amplitudes ( p  < .001), and n1-p2 amplitudes ( p  < .001), prolongation of p1 latencies ( p  = .003) were observed. No significant difference in the caloric test was found between the two groups., Conclusions and Significance: Disappearance or impairment of VEMPs could be observed in patients with severe OSA, and reflects different degrees of impairment in the utricle and saccule.

Objectives/hypothesis: Currently, it is possible to assess in vivo the morphology of each compartment of the endolymphatic spaces 4 hours after an intravenous administration of gadolinium on magnetic resonance imaging (MRI). The aim of this study was to assess the correlation between otolithic and ampullar functions (cervical vestibular evoked myogenic potential [cVEMP], ocular vestibular evoked myogenic potential [oVEMP], video head impulse test [VHIT]) and delayed inner ear MRI based on a compartmental, anatomically based classification that included the cochlea, the saccule, the utricle, and the ampullas., Study Design: Retrospective case-control study., Methods: In this retrospective study, we performed three-dimensional fluid-attenuated inversion recovery sequences with delayed acquisition in 26 healthy subjects and 31 definite Menière's disease (MD) patients. Each subject was then graded on MRI on the basis on cochlear, saccular, utricular, and ampullar hydrops in MD patients. All patients underwent pure-tone audiometry, VHIT, cVEMP, and oVEMP testing., Results: Cochlear, saccular, utricular, and ampullar hydrops were found on MRI in 88%, 91%, 50%, and 8.5% respectively. We found no significant correlation between the presence of saccular hydrops versus cVEMP, utricular hydrops versus oVEMP, and ampullar hydrops versus VHIT. However, the severity of endolymphatic hydrops on MRI was correlated to the degree of hearing loss., Conclusions: We proposed a compartmental, anatomically based classification for endolymphatic hydrops on MRI, which included the whole vestibular compartment. Using this classification, we observed increasing morphological changes as the disease evolved, affecting first the saccule, then the utricle, and finally the ampullas. The severity of vestibular endolymphatic hydrops is only correlated to hearing loss severity., Level of Evidence: 3 Laryngoscope, 130:E444-E452, 2020., (© 2019 The American Laryngological, Rhinological and Otological Society, Inc.)

Background: A negative potential is occasionally recorded in humans and animals with profound deafness during brainstem auditory evoked potential (BAER) tests if loud intensities are used. This acoustically evoked short latency negative response (ASNR) is hypothesized to be of saccular origin. The sensitivity to sound of vestibular end organs is also used to produce vestibular evoked myogenic potentials (VEMP), a test that evaluates vestibular function. The same saccular origin is accepted also for VEMP., Case Presentation: A neutered male white domestic short hair cat presented with profound deafness and an ASNR in the left ear during BAER test performed when he was 8 months old. BAER tracings were substantially unchanged at the age of 12 years, immediately before euthanasia that was requested by the owner for the presence of an unrelated neoplastic disorder. The cat underwent a complete post-mortem necropsy including histopathology of the middle and inner ears. Histopathologic results confirmed the presence of a cochleosaccular degeneration of the left ear while the cochlea and sacculus of the right ear and the utriculus and semicircular canals of both ears were histologically normal., Conclusions: This case report describes the auditory and histopathologic findings of a cat that showed an ASNR during BAER test despite the presence of cochleosaccular deafness. These results confirm that a saccular origin for the ASNR in this case, and in general in cats and dogs with congenital deafness associated with white pigmentation, is improbable. The hypothesis that the sacculus is the vestibular end organ responsible for the generation of the ASNR and VEMP in humans comes mainly from animal studies. The findings in this report may change the clinical interpretation of the results of BAER and VEMP not only in companion animals, but in humans as well.

Objectives: The aim of the present study was to compare the vestibular system integrity of individuals with normal hearing with that of prelingual hearing impaired individuals. It is well known that ocular vestibular evoked myogenic potentials (oVEMPs) reflect utricular function, whereas cervical vestibular evoked myogenic potentials (cVEMPs) reflect saccular function. Therefore, oVEMP and cVEMP tests were applied to evaluate the vestibular system integrity of hearing impaired individuals participating in the research., Materials and Methods: The study group consisted of sensorineural prelingual hearing-loss volunteers aged from 18 to 60 years, whereas the control group consisted of age- and gender-matched healthy volunteers. cVEMP and oVEMP tests were performed to evaluate the integrity of the vestibular system, and the results were compared with those of the control group., Results: The study included 20 (76.9%) women and 6 (23.1%) men in the study group; on the other hand, the control group consisted of 19 (73.1%) women and 7 (26.9%) men. There was a difference between the study group and the control group when oVEMP and cVEMP responses were compared, and the response percentage was higher in the control group. The response rates of oVEMP and cVEMP in patients with prelingual hearing loss were 44.2% and 59.6%, respectively. There was also a statistically significant difference between the groups for oVEMP amplitude and cVEMP P1 latency (p≤0.05)., Conclusion: These findings suggest that prelingual hearing loss is related to both utricular and saccular dysfunctions. However, oVEMPs were more often abnormal in prelingual deaf patients than cVEMPs, suggesting that utricular dysfunction may be more common than saccular dysfunction.

Objective: Functional integrity of vestibular end organs is essential for gaze stabilization, dynamic visual acuity, postural control and spatial orientation. Some authors hypothesized on the importance of saccules for postural control and motor development in children, including achievements such as standing up and walking. The purpose of this article was to observe how saccular dysfunction assessed by cervical Vestibular Evoked Myogenic Potentials (cVEMPs) correlates with the quality of postural control in non-syndromic deaf children., Method: Seventy-six non-syndromic hearing-impaired children were retrospectively included. Sacculo-collic pathway was assessed with cVEMPs elicited in bone conduction. The response was quoted "normal" if a reproducible wave P13-N23 of at least 50μV in amplitude was present, if not, it was quoted "absent". The sample was divided in 3 groups depending on the presence of the sacculo-collic responses: normal bilateral group (Group 1), normal unilateral (Group 2) and absent bilaterally group (Group 3). Motor assessment was achieved with Movement Assessment Battery for Children, second edition (MABC-2). Postural control (PC) was assessed using the dynamic Balance Quest platform. The scores obtained with MABC-2, and the postural parameters recorded on the Balance Quest platform (sway of Centre of Pressure and spectral power index) were analyzed and compared throughout the groups., Results: Group 1 (normal bilateral) showed the best scores regarding motor abilities and postural stability within available normative data. Group 3 (absent bilateral) had the lowest motor and postural control skills. A good correlation between the scores obtained by MABC-2 motor test and dynamic posturography (Balance Quest) was observed., Conclusions: The presence of at least one sacculo-collic response would predict satisfactory static and dynamic motor and postural control skills in non-syndromic hearing-impaired children. MABC-2 and Dynamic Posturography Balance Quest appears reliable and comparable tools for PC assessment in hearing impaired children. In the light of these results, it appears that in young children candidates for uni- or bilateral CI whose walking is not yet acquired, should receive a vestibular assessment before surgery to avoid the risk of bilateral sacculo-collic function impairment., Competing Interests: Declaration of competing interest The co-authors declare that they have no competing interests., (Copyright © 2019 Elsevier B.V. All rights reserved.)

The otolith organs play a critical role in detecting linear acceleration and gravity to control posture and balance. Some afferents that innervate these structures can be activated by sound and are at risk for noise overstimulation. A previous report demonstrated that noise exposure can abolish vestibular short-latency evoked potential (VsEP) responses and damage calyceal terminals. However, the stimuli that were used to elicit responses were weaker than those established in previous studies and may have been insufficient to elicit VsEP responses in noise-exposed animals. The goal of this study was to determine the effect of an established noise exposure paradigm on VsEP responses using large head-jerk stimuli to determine if noise induces a stimulus threshold shift and/or if large head-jerks are capable of evoking VsEP responses in noise-exposed rats. An additional goal is to relate these measurements to the number of calyceal terminals and hair cells present in noise-exposed vs. non-noise-exposed tissue. Exposure to intense continuous noise significantly reduced VsEP responses to large stimuli and abolished VsEP responses to small stimuli. This finding confirms that while measurable VsEP responses can be elicited from noise-lesioned rat sacculi, larger head-jerk stimuli are required, suggesting a shift in the minimum stimulus necessary to evoke the VsEP. Additionally, a reduction in labeled calyx-only afferent terminals was observed without a concomitant reduction in the overall number of calyces or hair cells. This finding supports a critical role of calretinin-expressing calyceal-only afferents in the generation of a VsEP response. NEW & NOTEWORTHY This study identifies a change in the minimum stimulus necessary to evoke vestibular short-latency evoked potential (VsEP) responses after noise-induced damage to the vestibular periphery and reduced numbers of calretinin-labeled calyx-only afferent terminals in the striolar region of the sacculus. These data suggest that a single intense noise exposure may impact synaptic function in calyx-only terminals in the striolar region of the sacculus. Reduced calretinin immunolabeling may provide insight into the mechanism underlying noise-induced changes in VsEP responses.

Vestibular sensorial input is essential for psychomotor development of the very small children. In consequence, possible vestibular impairment induced by cochlear implantation in deaf children could affect the balance and walking learning process. Some of cochlear implanted children can present congenital vestibular deficit. The anatomical and embryological relation between auditory and vestibular system explains why congenital neurosensorial hearing loss may associate vestibular impairment. The cochlear implant surgery presents a vestibular lesion risk. Bilateral vestibulopathy, as it appears in early childhood, has a poor prognosis for the psychomotor and cognitive development. Even probably rare, bilateral vestibulopathy induced by simultaneous bilateral cochlear implantation can delay the acquisition of motor skills. This pathology can be avoided by an appropriate surgical indication related to the vestibular preoperative status. This study reports the vestibular saccular functional modifications after the cochlear implantation in children. The cervical vestibular evoked myogenic potentials (cVEMPs) were performed in children before and after the cochlear implantation. Since previous studies report different vestibular impairment related to the portelectrode insertion approach, another objective of our study was to assess the saccular postoperative status depending of the insertion by cochleostomy (CO) or through the round window (RW). We performed cVEMPs for 80 patients (135 cochlear implanted ears) before and after cochlear implantation. We have detected preoperative saccular areflexia in 33 (24.4%) ears. In the group of 102 (75.6%) ears with preoperative normal saccular function, 72 (70.6%) ears preserved the cVEMP response after the surgery, while in 30 (29.4%) ears the cVEMP response was lost. Reporting our findings to the portelectrode insertion method, we found normal saccular function in 73.3% of the cochlear implanted ears by RW surgical approach and in 68.42% ears by CO approach. These results suggest that the RW portelectrode insertion is the recommended strategy in order to avoid the saccular vestibular impairment.

Purpose: As the pathological cause of benign paroxysmal positional vertigo (BPPV), the dislocation or degeneration of otoconia in the utricle and saccule is suggested. Vestibular evoked myogenic potential (VEMP) could reflect otolithic dysfunction due to these etiologies of BPPV. The aim of this study was to validate the clinical significance of cervical (c) and ocular (o) VEMP in BPPV by a meta-analysis of previous articles., Methods: Articles related to BPPV with data on cVEMP and oVEMP were collected. The following keywords were used to search PubMed and Scopus for English language articles: benign paroxysmal positional vertigo or BPPV and vestibular evoked myogenic potential or VEMP., Results: The p13 latency in cVEMP and n1 latency in oVEMP were slightly but significantly prolonged in BPPV patients compared to control patients. AR in oVEMP of BPPV patients also showed higher value than that of control patients. However, the n23 latency and AR in cVEMP and p1 latency in oVEMP showed no significant difference between BPPV and control patients. Furthermore, latencies in VEMPs also showed no significant difference between an affected and a non-affected ear in BPPV patients., Conclusions: Our results indicated that otolith dysfunction of BPPVs was detected by latencies in VEMPs, and AR in oVEMP more sensitively reflects the difference between affected and non-affected ears in BPPV patients. The otolith dysfunction of BPPV might be induced by the systemic condition. However, the differences of latencies between BPPV patients and control patients were too small to use VEMPs as a prognostic predictor.

Objective: The aim of this study was to investigate whether the insertion of an implant into the cochlea is accompanied by a deterioration in otolith function. Cervical and ocular vestibular evoked myogenic potentials (cVEMP and oVEMP) and linear vestibulo-ocular reflex (lVOR) during eccentric rotation were assessed before and after cochlear implantation (CI) to evaluate otolith function., Methods: Twelve patients with bilateral severe sensorineural hearing loss who had undergone CI surgery in our hospital between May 2016 and November 2017 were included in this study. cVEMP and oVEMP were assessed using the asymmetry ratio (AR), calculated with the following formula: [(peak-to-peak amplitude calculated as the sum of the p13 and n23 amplitudes in the non-operated side) - (that in the operated side)]/[(that in the non-operated side) + (that in the operated side)]. The ratio of VOR gain during eccentric rotation against VOR gain during center rotation was used to assess lVOR. For eccentric rotation, patients were rotated while displaced from the axis of rotation. At the same time, linear acceleration stimulated the utricle and induced lVOR. All patients underwent cVEMP and oVEMP tests and center and eccentric rotation tests before and about 30days after CI surgery., Results: Three patients with absent cVEMP responses before surgery were excluded, leaving pre-surgery cVEMP results for 9/12 patients. In five of these patients, the AR of cVEMP increased after CI, indicating that saccular function, as evaluated by cVEMP, did not deteriorate significantly postoperatively. One patient with an absent oVEMP response before CI was excluded, leaving pre-surgery oVEMP results for 11/12 patients. In 10 of these patients, the AR of oVEMP increased after CI surgery, indicating that utricular function, as evaluated by oVEMP, deteriorated significantly postoperatively. However, because the ratio of VOR gain during eccentric rotation against VOR gain during center rotation did not become worse after CI, utricular function, as evaluated by lVOR, did not deteriorate significantly postoperatively. Symptoms of vertigo became worse after CI in two of the 12 patients., Conclusion: CI does not cause a deterioration in saccular function, as evaluated by cVEMP. Although CI does cause a deterioration in utricular function in oVEMP tests, this is not consistent in lVOR tests. These results indicate that CI causes a slight deterioration in utricular function that is insufficient to cause vertigo or deterioration of lVOR., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Background: Patients with Meniere's disease (MD) may present with peripheral vestibular end organ dysfunction and balance dysfunction. Objective: This study aimed to compare the results of vestibular evoked myogenic potential (VEMP) tests with those of the sensory organization test (SOT) in patients with MD to determine whether they are correlated. Material and methods: In total, 132 patients with unilateral MD were evaluated using an audiometric test, the SOT, a caloric test and VEMP tests. Results: Cervical VEMP and ocular VEMP tests were conducted in 132 patients with MD, and the response rates of the affected side were lower than those of the unaffected side. The composite score, C5 ES , and C6 ES of the SOT were significantly decreased in patients with no VEMP responses compared to those with VEMP responses. Conclusions and significance: MD patients with no VEMP responses are more likely to develop balance impairment than those with VEMP responses. MD patients with otolith organ impairment may therefore have balance disorders, and should exercise caution to prevent falls and subsequent injuries.

Purpose: To evaluate the function of the utriculus and sacculus and their central connections by ocular and cervical vestibular-evoked myogenic potentials (oVEMPs and cVEMPs), and the function of high-frequency VOR of the semicircular canals by video head impulse test (vHIT) in patients with panic disorder (PD)., Methods: Forty-eight patients with PD (21 with agoraphobia) and 20 sex- and age-matched healthy controls took part in the investigation. The vestibulo-ocular reflex (VOR) gains and latencies and peak-to-peak amplitudes of sound-induced VEMPs were measured and compared with those of healthy controls., Results: Any statistical differences in the parameters of cVEMP and oVEMP responses between both PD patients groups and between patients and healthy controls were not observed. Also, significant differences between VOR in patients and healthy controls were not found. The VOR gain, bilaterally in the three semicircular canals was within normal limits (0.8-1.2) for 67%, and higher for 33% of the patients with PD. Overt and covert saccades were not observed. The relationship between higher VOR gains and the increase of postural instability when a sensory conflict exists (standing on foam pad with eyes closed) for patients with PD was established., Conclusion: The VEMPs and vHIT tests demonstrated that there is no evidence of hypofunction of the semicircular canals in the high-frequency spectrum of VOR functioning. Nor are there any indications of impairment of the otolith system in patients with PD, regardless of their subjective vestibular sensations. The findings of the current study confirm the proposed link between anxiety, panic symptoms and postural instability in PD patients.

Brg1 is an ATPase subunit of the SWI/SNF chromatin-remodeling complex, and it is indispensable for the development and homeostasis of various organs. Conditional deletion of Brg1 in cochlea hair cells (HCs) leads to multiple structural defects and profound deafness. However, the premature death of Brg1-deficient cochlea HCs hindered further study of the role of Brg1. In contrast to cochlea HCs, Brg1-deficient vestibular HCs survived for a long time. Therefore, HC apical structure and vestibular function were examined in inner HC-specific conditional Brg1 knockout mice. Vestibular HCs exhibited fused and elongated stereocilia bundles after deletion of Brg1, and the cuticular plate was absent in most HCs with fused stereocilia bundles. HC loss was observed in conditional Brg1 knockout mice at the age of 12 months. Morphological defects and HC loss were primarily restricted in the striolar region of the utricle and saccule and in the central region of ampulla. The behavioral tests revealed that Brg1 deletion in HCs caused vestibular dysfunction in older adult mice. These results suggest that Brg1 may play specific roles in the maintenance of the HC stereocilia bundle and the cuticular plate., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Vestibular neuritis (VN) can affect utricular afferents. Utricular function can be assessed by ocular vestibular evoked myogenic potentials (oVEMPs) whose abnormalities include weak or absent responses, and ocular cycloposition whose abnormalities include ocular torsion (OT). When studied independently in vestibular neuritis, oVEMPs are abnormal in 61-82% of cases, and OT is present in 72-80% of cases. The similar range of abnormalities suggests the hypothesis that these tests should be concordantly abnormal. We tested this hypothesis by identifying consecutive adult cases of VN in whom both oVEMPs and OT were performed. OT and oVEMP overlapped (both were abnormal) in only 47% of cases. In 40% of cases oVEMPs alone were abnormal, and in 13% of cases, OT alone was present. These results suggest that oVEMPs and OT assess different aspects of utricular function believed to arise from discrete zones of the utricular macula; the former are thought to reflect the activity of extra-striolar afferents (which detect constant acceleration), and the latter reflects the activity of striolar afferents (which detect change in acceleration).

Objective: This study attempted to identify systemic factors for age-related decline in neural function originating from the saccule using cervical vestibular-evoked myogenic potentials (cVEMP) parameters., Methods: We recruited 129 symptomatic vertiginous patients who did not have known disorder affecting the cVEMP pathway (mean age = 52.4 ± 13.9). The indicators of saccule-related neural function were the sum of normalized cVEMP amplitude (SNA) and the average of p13 latency on both sides (average latency, AL). Any associations between cVEMP and systemic factors were evaluated using a linear regression., Result: SNA decreased with ageing (p < 0.001) in univariable regression. The estimated glomerular filtration rate (eGFR) was positively associated with SNA (p = 0.002). Hematocrit, C-reactive protein, vitamin D, and free thyroxine (T4) showed a trend of association with SNA (p < 0.2). SNA was associated with ageing, increased free T4, and decreased eGFR in multivariable analysis. In the subgroup analysis, SNA was significantly associated with free T4 in younger patients (mean age = 41.5 ± 9.91) but not in the older ones (mean age = 63.5 ± 6.54). AL did not show any significant associations with systemic factors., Conclusion: Decreased eGFR and increased free T4 as well as aging may be risk factors for decline of saccule-related neural function., Significance: Neural function originating from the saccule may be affected by systemic factors., (Copyright © 2019 International Federation of Clinical Neurophysiology. Published by Elsevier B.V. All rights reserved.)

Introduction: Benign paroxysmal positional vertigo (BPPV) pathophysiology is based on otoconia migration from the utricle and saccule to the semicircular canals, however, the role of the saccule is still under study. Our aim is to study the otolith damage in these patients with vestibular evoked myogenic potentials (VEMPS) and correlate the results with those of computerised dynamic posturography (CDP)., Material and Methods: We present 79 patients diagnosed with BPPV between March and June 2017. VEMPS and CDP studies were performed. We selected 67 patients with posterior semi-circular canal BPPV and we compared them with 60 healthy subjects., Results: BPPV group had abnormal cervical VEMPS in 49.25% of patients compared to 16.67% in the control group. Ocular VEMPS were altered in 61.19% of the patients and 6.67% of the healthy subjects. Abnormal ocular VEMPS in patients with recurrent BPPV was statistically significant. There was no significant correlation with CDP results., Conclusions: Utricular and saccular dysfunction in BPPV patients proved by VEMPS is higher than in healthy individuals. This result may be related to symptoms of instability experienced by these patients occasionally., (Copyright © 2018 Sociedad Española de Otorrinolaringología y Cirugía de Cabeza y Cuello. Publicado por Elsevier España, S.L.U. All rights reserved.)

Objective: We aimed to describe vestibular/oculomotor function of 7-12-year-old children with CP, Gross Motor Function Classification System (GMFCS) levels (I-III), in comparison to an age-matched control group to understand the effect of the vestibular system on activities and participation of children with CP., Methods: Vestibular, oculomotor and balance function were tested in children with CP. Central and peripheral vestibular function was examined using an enclosed rotary chair and infrared video goggles (100 Hz) that measured eye movements. Oculomotor tests included smooth pursuit and optokinetic nystagmus (OKN). Vestibulo-Ocular Reflex (VOR) tests, done in complete darkness, included step rotation (STEP), sinusoidal harmonic acceleration (SHA) test, VOR cancellation and enhancement, and subjective visual vertical and horizontal (SVV/SVH). The integrity of the saccule was tested with the Cervical Vestibular Evoked Myogenic Potential. If able, the participants' balance abilities were examined using the Sensory Organization Test (SOT) to determine ability to maintain standing balance during six conditions that challenged the visual, somatosensory and vestibular systems. Independent t-tests and Mann-Whitney U tests were used to compare results between groups., Results: Forty-one children with CP (mean age = 9.44 years, SD = 1.66; 23F/18M; Gross Motor Function Classification System levels: I (n = 19), II (n = 7), III (n = 15) and thirty-three typically developing (TD) children (mean age = 10.16 years, SD = 1.6; 13F/20M) were recruited from the Birmingham, AL community. There was no significant difference between children with CP and TD children in saccular function (i.e. C-VEMP test), and peripheral vestibular end organ (i.e. SHA test and STEP test), VOR enhancement, or OKN gain. Velocity gain for horizontal smooth pursuit was significantly worse in children with CP (p = 0.009), compared to TD children. Poor mediation of central vestibular function were that evident with significantly higher VOR cancellation gain in children with CP (p < 0.0001), compared to TD children and significantly higher SVV variance (p = 0.002), SVH mean (p = 0.001), and SVH variance (p < 0.0001) in children with CP compared to TD children. Compromised balance abilities in children with CP was evident with significantly lower composite scores (p < 0.0001), vestibular ratio (p < 0.0001), and visual ratio (p = 0.021). The somatosensory ratio (p = 0.798) of children with CP was similar to children with TD., Conclusions: Although peripheral vestibular function was intact, children with CP had difficulty coupling eye and head movement (VOR cancellation), using the vestibular system for postural control (SOT), demonstrated poor perception of upright (SVV/SVH), and had difficulty following a slow moving target (smooth pursuit eye movement). These results implicate a central vestibular and oculomotor function impairment the severity of which corresponded with severity of the level of CP., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Objective: To evaluate all five vestibular end-organ functions (lateral, anterior, posterior semicircular canal, utricule, and saccule) and to investigate the relationship between Dizziness Handicap Inventory (DHI) and vestibular functions prior to CI (cochlear implantation) and at postoperative day 3 and month 3., Methods: A total of 42 patients (age 16-70years) with normal vestibular functions preoperatively and undergoing unilateral CI were included in this prospective descriptive study. Video head impulse test (vHIT) for three semicircular canal (SSC) functions, ocular vestibular-evoked myogenic potential (oVEMP) for utricule function, cervical vestibular-evoked myogenic potential (cVEMP) for saccule function and DHI for subjective vertigo symptoms were performed prior to CI and at postoperative day 3 and month 3., Results: There was a significant impairment of vestibular function in 12 patients (28.5%) on the implantation side and significant DHI increase was observed in 13 of 42 (30.9%) patients at postoperative day 3 after CI (p<0.05). We found SSC dysfunction in 7 patients (16,6%) who underwent observation with vHIT, saccule dysfunction in 8 patients (19%) with cVEMP and utricule dysfunction in 5 patients (11.9%) with oVEMP on the operated side 3days after surgery (p<0.05). Posterior SSC functions (5 patients) were more affected than lateral SSC functions (3 patients). At postoperative month 3, six patients (14.2%) still had deteriorating results in the objective tests and significant DHI increase was continued in 4 (9.5%) patients (p<0.05). The deterioration in vHIT continued in only 1 (2.3%) patient (p>0.05). The deterioration in cVEMP continued in 5 (11.9%) patients (p<0.05). The deterioration in oVEMP continued in 2 (4.7%) patients (p>0.05). There was a significant correlation between DHI and objective vestibular tests both in the early and late postoperative period (r=0.795; p<0.05)., Conclusion: Our study showed that both canal and otolith functions can be damaged after CI especially in the early postoperative period. Surprisingly, posterior SSC functions were more affected than lateral SSC. Therefore, a gold standard vestibular test battery that can evaluate each of three SSC canals and two otoliths functions is essential. Since a single vestibular test for this purpose is not available, we recommend the use of the three available vestibular tests together. This test battery, which is capable of evaluating five vestibular end-organ functions in preoperative and postoperative vestibular evaluations, can provide more accurate results not only for CI but also for most otologic surgeries., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Background: The vestibular membranes of the cochlea and saccule are subject to two simultaneous constraints as they deform in endolymphatic hydrops. Boundary tethers impose a bulge-type constraint during pressure-induced transverse membrane displacement, while inherent elasticity imposes a stretch-type constraint during stress-induced longitudinal membrane distention., Objective: The aim of this study is to reconcile the effect of these dual constraints on membrane deformation. It is hypothesized that it is the interaction of these constraints that determines whether a stable membrane configuration can be achieved or progression to endolymphatic hydrops will occur., Methods: Reissner's membrane was modeled as a flat elastic ribbon that was bound along its lateral edges and subject to trans-mural pressure. The bulge and stretch constraints on membrane deformation were formulated mathematically. A graphic solution of the constraint functions was used to examine the nature of the interaction and determine how pressure and elasticity influence the hydropic process., Results: The graphic analysis shows how bulge and stretch phenomena interact to achieve an equilibrium point that satisfies both physical requirements. Nominal values of pressure and elasticity are projected to result in a stable membrane equilibrium in the precritical zone with the modest isolated increases in either parameter alone compatible with stability. However, a sufficiently large increase in either pressure or elasticity alone can constitute a single hit mechanism to exceed the critical point and destabilize the membrane. Moreover, simultaneous modest increases in both pressure and elasticity, neither of which would be sufficient in its own right, can be additive and constitute a double hit mechanism to destabilize the membranes as well. Finally, extreme values of pressure and elasticity that fail to intersect imply that no solution is feasible and that the affected membranes will fail immediately., Conclusions: Sufficiently large increases in either endolymphatic pressure or membrane elasticity alone can destabilize the membranes and constitute single hit mechanisms for inducing hydrops. Combined moderate increases in both trans-mural pressure and membrane elasticity can also destabilize the membranes and constitute a double hit mechanism for hydrops induction.

Objectives: A case-controlled imaging study demonstrated that saccular hydrops was specific to Meniere's disease (MD), but only present in a subset of patients. Here, we compared patients with definite MD, vertigo and sensorineural hearing loss (SNHL) to elucidate the relationship between saccular hydrops and extent of SNHL., Methods: In this prospective study, we performed 3D-FLAIR sequences between 4.5 and 5.5 h after contrast media injection in patients with MD (n=20), SNHL (n=20), vertigo (n=20) and 30 healthy subjects. Two radiologists independently graded saccular hydrops. ROC analysis was performed to determine the hearing loss threshold to differentiate patients with saccular hydrops., Results: Saccular hydrops was found in 11 of 20 MD patients, 10 of 20 SNHL patients and in none of the vertigo patients and healthy subjects. In SNHL patients, 45 dB was the threshold above which there was a significant association with saccular hydrops, with sensitivity of 100 % and specificity of 90 %. In MD patients, 40 dB was the threshold above which there was a significant association with saccular hydrops, with sensitivity of 100 % and specificity of 44 %., Conclusions: Our results indicate saccular hydrops as a feature of worse than moderate SNHL rather than MD itself., Key Points: • MRI helps clinicians to assess patients with isolated low-tone sensorineural hearing loss. • Saccular hydrops correlates with sensorineural hearing loss at levels above 40 dB. • Vertigo patients without sensorineural hearing loss do not have saccular hydrops. • Saccular hydrops is described in patients without clinical diagnosis of Meniere's disease.

Objective: Gait imbalance in patients with bilateral-vestibular-deficiency (BVD) was linked to increased variability in perceived direction of gravity while upright. We hypothesized this to be true also when roll-tilted. Moreover, as utricular input is essential for spatial orientation, we predicted the variability of perceived vertical to correlate inversely with utricular function., Methods: Subjective visual vertical (SVV) and haptic vertical (SHV) were measured in various roll-orientations (0°/±45°/±90°) and postural adjustments along earth-vertical/earth-horizontal were collected in patients with partial BVD (n = 10) and healthy controls (n = 11). Patients with bilaterally-absent bone-conducted ocular vestibular-evoked myogenic-potentials (oVEMPs) were compared to those with (partially) preserved oVEMPs., Results: For the SVV (p < 0.001) and SHV (p = 0.004) variability was larger in patients than controls. Compared to those with (partially) preserved oVEMPs, patients with bilaterally-absent oVEMPs had higher SVV (p = 0.024) and SHV (p = 0.006) variability. Self-positioning along earth-horizontal was more variable in BVD-patients compared to controls (p < 0.001). Again, variability was higher in those with bilaterally-absent oVEMPs (p = 0.032). SVV/SHV-variability was correlated (R 2  = 0.61, slope = 1.06 [95%-CI = 0.80-1.54]) in BVD-patients., Conclusion: With variability correlating amongst the different paradigms and with oVEMP-responses, this emphasizes the role of bilaterally intact utricular input for precise perception of gravity., Significance: In BVD-patients with bilaterally-absent oVEMPs intensified vestibular rehabilitation should be considered., (Copyright © 2018 International Federation of Clinical Neurophysiology. Published by Elsevier B.V. All rights reserved.)

Background: The cervical vestibular evoked myogenic potential (cVEMP) test measures saccular and inferior vestibular nerve function. The cVEMP can be elicited with different frequency stimuli and interpreted using a variety of metrics. Patients with superior semicircular canal dehiscence (SCD) syndrome generally have lower cVEMP thresholds and larger amplitudes, although there is overlap with healthy subjects. The aim of this study was to evaluate which metric and frequency best differentiate healthy ears from SCD ears using cVEMP., Methods: Twenty-one patients with SCD and 23 age-matched controls were prospectively included and underwent cVEMP testing at 500, 750, 1,000 and 2,000 Hz. Sound level functions were obtained at all frequencies to acquire threshold and to calculate normalized peak-to-peak amplitude (VEMPn) and VEMP inhibition depth (VEMPid). Third window indicator (TWI) metrics were calculated by subtracting the 250-Hz air-bone gap from the ipsilateral cVEMP threshold at each frequency. Ears of SCD patients were divided into three groups based on CT imaging: dehiscent, thin or unaffected. The ears of healthy age-matched control subjects constituted a fourth group., Results: Comparing metrics at all frequencies revealed that 2,000-Hz stimuli were most effective in differentiating SCD from normal ears. ROC analysis indicated that for both 2,000-Hz cVEMP threshold and for 2,000-Hz TWI, 100% specificity could be achieved with a sensitivity of 92.0%. With 2,000-Hz VEMPn and VEMPid at the highest sound level, 100% specificity could be achieved with a sensitivity of 96.0%., Conclusion: The best diagnostic accuracy of cVEMP in SCD patients can be achieved with 2,000-Hz tone burst stimuli, regardless of which metric is used., (© 2019 The Author(s) Published by S. Karger AG, Basel.)

Objective: Cervical spondylosis and cervical disk herniation are the most frequent forms of degenerative disease in the cervical spine. Surgical treatment mainly includes anterior cervical disk fusion. However, information concerning vestibular-evoked myogenic potential (VEMP) recording in patients undergoing cervical spine surgery is limited. The present prospective study aimed to investigate the effect of anterior disk fusion surgery on cervical VEMP (cVEMP) parameters., Materials and Methods: Twenty-five patients were enrolled in this study, and 20 patients (10 men and 10 women) completed cVEMP testing. Patient ages ranged from 29 to 76 y (mean, 52 y). Patients with conductive hearing loss or vestibular dysfunction were excluded. The cVEMP test was recorded preoperatively and 1 and 4 months postoperatively. Air-conducted tone-bursts of 500 Hz were used., Results: We found no statistically significant difference between the preoperative and postoperative cVEMP values., Conclusion: Cervical spine surgery (anterior cervical disk fusion) for treating cervical spondylosis does not appear to affect the presence of cVEMP or the parameters of cVEMP, when using air-conducted tone-bursts of 500 Hz. Moreover, cVEMP testing can be used in the postoperative phase for evaluating vertigo in patients who have undergone anterior cervical disk fusion.

Objective: Over the last decade, ocular vestibular evoked myogenic potentials (oVEMPs) have evolved as a new clinical test for dynamic otolith (predominantly utricular) function. The aim of this review is to give an update on the neurophysiological foundations of oVEMPs and their implications for recording and interpreting oVEMP responses in clinical practice., Conclusion: Different lines of anatomical, neurophysiological, and clinical evidence support the notion that oVEMPs measure predominantly contralateral utricular function, while cervical cVEMPs are an indicator of ipsilateral saccular function. Bone-conducted vibration (BCV) in the midline of the forehead at the hairline (Fz) or unilateral air-conducted sound (ACS) are commonly used as stimuli for oVEMPs. It is recommended to apply short stimuli with short rise times for obtaining optimal oVEMP responses. Finally, this review summarizes the clinical application and interpretation of oVEMPs, particularly for vestibular neuritis, Ménière's disease, superior canal dehiscence and "challenging" patients.

Objective: We used ocular vestibular evoked myogenic potentials to investigate the relationship between residual dizziness and utricular function following the canalith repositioning procedure for benign paroxysmal positional vertigo., Methods: Ocular vestibular evoked myogenic potentials were measured in 44 patients (40 included in analyses, four excluded) with successful results from the canalith repositioning procedure. The patients were examined before treatment and again one week after treatment. We analyzed how various general factors and ocular vestibular evoked myogenic potentials related to residual dizziness., Results: Residual dizziness was not related to gender, affected side, age, duration of symptoms, recurrence, or the results of the initial ocular vestibular evoked myogenic potential test (p > .05). However, residual dizziness was significantly associated with the results of the second ocular vestibular evoked myogenic potential test (p = .007)., Conclusions: Residual dizziness after a successful canalith repositioning procedure may be caused by persistent utricular dysfunction.

Conclusion: Our study showed that sensory organization test (SOT) could principally reflect utricular function, and our cut-score of VEST ratio (the indicator of inputs from the vestibular system in balance performance) in SOT could help to screen patients with unilateral peripheral vestibular dysfunction in non-fallers., Objectives: We aimed to know SOT reflects the function of which vestibular end organs and to assess the possibility of screening patients with peripheral vestibular dysfunction in non-fall population by means of SOT., Methods: A total of 75 patients with unilateral peripheral vestibular dysfunction underwent SOT, ocular vestibular-evoked myogenic potential (oVEMP), cervical vestibular-evoked myogenic potential (cVEMP) and caloric tests., Results: Regression model indicated that oVEMP, as an independent variable, exerted the greatest influence on VEST ratio, followed by age and cVEMP. There were no significant differences in VEST ratio among groups with different extents of peripheral vestibular involvement (p > .05). VEST ratio in the vestibular impairment groups was significantly lower than in the control group and significantly higher than in fall group (p < .01). VEST ratio in group with normal oVEMP was significantly higher than in group with abnormal oVEMP (p = .013). The cut-score between populations with functional and dysfunctional vestibule was 0.649.

The damaged vestibular sensory epithelium of mammals has a limited capacity for spontaneous hair cell regeneration, which largely depends on the transdifferentiation of surviving supporting cells. Little is known about the response of vestibular supporting cells to a severe insult. In the present study, we evaluated the impact of a severe ototoxic insult on the histology of utricular supporting cells and the changes in innervation that ensued. We infused a high dose of streptomycin into the mouse posterior semicircular canal to induce a severe lesion in the utricle. Both scanning electron microscopy and light microscopy of plastic sections showed replacement of the normal cytoarchitecture of the epithelial layer with a flat layer of cells in most of the samples. Immunofluorescence staining showed numerous cells in the severely damaged epithelial layer that were negative for hair cell and supporting cell markers. Nerve fibers under the flat epithelium had high density at the 1 month time point but very low density by 3 months. Similarly, the number of vestibular ganglion neurons was unchanged at 1 month after the lesion, but was significantly lower at 3 months. We therefore determined that the mouse utricular epithelium turns into a flat epithelium after a severe lesion, but the degeneration of neural components is slow, suggesting that treatments to restore balance by hair cell regeneration, stem cell therapy or vestibular prosthesis implantation will likely benefit from the short term preservation of the neural substrate., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Objectives: A new method for the treatment of a subtype of postural unsteadiness frequently seen in the medical office is proposed. Ten years of successful practical application and continuous refining of this new treatment lead to the definition of symptom-criteria, which are useful to distinguish patients, who get benefit by this new procedure and to a modified model of the utricular macula., Materials and Methods: In a retrospective collection, the data of 15 patients with postural unsteadiness (mean duration of symptoms 61.7 months) successfully treated with the new maneuver are reported. Before treatment, all patients showed normal results in testing the caloric responses of the labyrinth, normal neurological investigation and no signs for cervical vertigo. Before and after treatment the DHI-score (Dizziness Handicap Index) was achieved by using the German version of the DHI-questionnaire. In all groups before and after treatment balance testing was performed using a posturography platform., Results: Application of the new treatment lead to a significant improvement of the DHI-scores and of the posturographic results (significant reduction of body sway)., Discussion: The patients, who were successfully treated by the new maneuver have had presented the same symptoms like patients with a proven utricular dysfunction. This leads to a slightly modified model of the utricular macula. Beyond correctly positioned otoconia in the utricular macula and free otoconia in the endolymphatic utricular space, a third fraction of dysfunctional partially detached otoconia is postulated (causing the unsteadiness). Based on this theory, the single hair-cell with its accompanied otoconium might be the smallest receptor-unit of the macula-organ. This smallest receptor-unit might represent a biological mass-spring-system. According to technical mass-spring-systems used as accelerometers, the different sizes of the otoconia for a distinct direction of acceleration are necessary for covering different frequency-bands. Finally, a many years successfully tested modified variation of the new maneuver for treatment in the medical office and for self-treatment is proposed., Competing Interests: Interessenkonflikt: Der Autor gibt an, dass kein Interessenkonflikt besteht.

The aim of this study was to assess the function of the utricle and horizontal semicircular canals in patients with type 2 diabetes mellitus receiving primary health care, with/without a history of falls. 101 patients with type 2 diabetes mellitus, 34 to 84 years old (26 with and 75 without a history of falls) and 51 healthy volunteers (40-83 years old) accepted to participate. They denied having a history of dizziness, vertigo, unsteadiness, hearing loss, or neurological disorders. None of them were seeking care due to sensory or balance decline. After a clinical evaluation and report of symptoms related to balance using a standardised questionnaire, lateral canal function was assessed by sinusoidal rotation at 0.16 Hz and 1.28 Hz (60°/sec peak velocity), otolith function was assessed by static visual vertical (average of 10 trials) and dynamic visual vertical during unilateral centrifugation (300°/sec at 3.5 cm) and static posturography was performed on hard/ soft surface with eyes open/closed. Compared to healthy volunteers, patients showed decreased responses to unilateral centrifugation, but similar responses to horizontal canal stimuli (independently of age, peripheral neuropathy or a history of falls) (ANCoVA p < 0.05) and a larger sway area with a lengthier sway path. Compared to patients with no falls, patients with falls had a higher female/male ratio and a higher frequency of score ≥ 4 on the questionnaire of symptoms related to balance, but similar age, body mass index and frequency of peripheral neuropathy. In patients with type 2 diabetes mellitus, receiving primary healthcare who are not seeking care due to sensory or balance decline, utricular function may be impaired even in the absence of horizontal canal dysfunction or a history of falls., (© Copyright by Società Italiana di Otorinolaringologia e Chirurgia Cervico-Facciale, Rome, Italy.)

Objective: We attempted to investigate whether the integrity of saccular function influences the severity of subjective dizziness after vestibular rehabilitation in vestibular neuritis., Study Design: Retrospective analysis., Setting: Tertiary referral center., Patients: Forty-six patients with acute unilateral vestibular neuritis were included., Interventions: Diagnostic, therapeutic, and rehabilitative., Main Outcome Measures: All the patients completed vestibular rehabilitation therapy until their computerized dynamic posturography and rotary chair test results were significantly improved. The rehabilitation patients were classified into the normal to mild subjective dizziness and moderate to severe subjective dizziness groups according to the dizziness handicap inventory score (cutoff of 40). Differences between the two groups were analyzed., Results: After rehabilitation, 32.6% of the patients still complained of moderate to severe dizziness. Age, sex distribution, the presence of comorbidities, caloric weakness, pre- and postrehabilitation gain values in rotary chair test, postrehabilitation composite scores in posturography, and the duration of rehabilitation were not significantly different between the two groups. However, initial dizziness handicap inventory (DHI) score and composite score in dynamic posturography were worse and the proportion of patients with absent cervical vestibular-evoked myogenic potential in the moderate to severe group was much higher (93.3% vs. 35.5%, p < 0.001). After multiple regression analysis of those factors, initial DHI score and absent cervical vestibular-evoked myogenic potential response were identified as being associated with higher postrehabilitation DHI score., Conclusion: Saccular dysfunction in acute vestibular neuritis can contribute to persistent subjective dizziness, even after the objective parameters of vestibular function tests have been improved by vestibular rehabilitation.

Objective: To demonstrate positional nystagmus during a head-roll test in two patients with lateral semicircular canal (LSCC) cupulolithiasis who presented with spontaneous detachment of otoliths from the LSCC cupula, and to confirm that otoliths may adhere to both the utricle and canal sides of the cupula., Patients and Methods: Using video nystagmography, positional nystagmus was evaluated in two patients with LSCC cupulolithiasis who showed the change of nystagmus direction during a head-roll test., Results: Both patients presented with persistent left-beating and right-beating nystagmus when the head was bent forward and backward, respectively. This suggests the presence of either cupulolithiasis on the right side or light cupula on the left side of the LSCC. In Case 1, transformation from cupulolithiasis to canalolithiasis occurred, implicating the detachment of otoliths from the canal side of the right LSCC cupula. In Case 2, vigorous right-beating nystagmus was followed by persistent left-beating nystagmus when the head was rolled to the left. Following this, direction-fixed left-beating nystagmus was observed at all positions, which may indicate that otoliths attached on utricle side of the right LSCC cupula were detached and fell into the utricle under the influence of gravity. A conversion of nystagmus direction may be explained by an expression of short-term adaptation of vestibular tone., Conclusions: Otoliths can be attached to either side of the cupula in LSCC cupulolithiasis. Because it is difficult to determine the attached side at the time of diagnostic maneuver, the therapeutic approach should include maneuvers designed to detach otolith particles from both the utricle and canal side., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Meniere's disease is the disorder of inner ear characterized by vertigo, tinnitus and sensorineural hearing loss. The vestibular evoked myogenic potential (VEMP) test could be useful in the analysis of saccular function, and diagnosis of Meniere's disease. In this study, we've analyzed the saccular function, using VEMP test in different groups of Meniere's disease. Patients were categorized as possible, probable or definite Meniere's disease groups according to the guideline of American Academy of Otolaryngology-Head and Neck Surgery. The exclusion criteria were neuromuscular system diseases, diseases of central nervous system, inner ear disorders, conductive hearing loss, a history of ototoxic drug consumption, being a drug abuser and a positive history of inner ear surgery or manipulations. The VEMP test is the recording of positive and negative waves from sternocleidomastoid muscle that is made by an auditory click to the ear. From the total of 100 patients, the waves of VEMP test was seen in 59 patients which 19 patients had abnormal amplitude, and latency and 40 patients were with normally recorded waves. There was a significant relationship between the severity of hearing loss and a VEMP test without any recorded waves. Most of the cases with 'no wave recorded' VEMP test, were patients with severe hearing loss. However, there wasn't any relation between the pattern of hearing loss and 'no wave recorded' VEMP test. VEMP test could be a valuable diagnostic clue especially in patients with definite Meniere's disease.

Ménière's disease is an inner ear disorder characterized by vertigo attacks, fluctuating and progressive hearing loss, tinnitus, and aural fullness in the affected ear. The pathophysiology of Ménière's disease remains elusive. Theories so far are anatomical variation in the size or position of the endolymphatic sac and duct, viral inflammation or autoimmune involvement of the sac, or a genetically determined abnormality of endolymph control. Animal studies on blocking the ductus reuniens and endolymphatic duct have produced hydrops in the cochlea, saccule, and utricle. Cone beam computed tomography images show a similar pattern with apparent obstruction of the ductus reuniens, saccular duct, and endolymphatic sinus. New studies documenting the age of onset of Ménière's disease show a pattern similar to benign paroxysmal positional vertigo, raising the possibility that the fundamental cause of Ménière's disease might be detached saccular otoconia.

Background: We have developed a non-invasive, behavioral measure of ocular alignment using a computer tablet, colored lenses, and touch screen software., Objective: The goal of this study was to determine if these tests differentiate healthy controls from patients with vestibular disorders., Methods: In the vertical alignment nulling test (VAN), subjects were asked to adjust a horizontal line that was offset vertically from a fixed horizontal line. In the torsional alignment nulling test (TAN) subjects were asked to adjust a line that was rotationally offset (i.e. clockwise) from a fixed horizontal line. We measured VAN and TAN in 14 healthy controls and 8 patients with known vestibular disorders., Results: Patients had significantly worse scores than controls on TAN, (mean 2.2 vs 0.75, p = 0.01), and no differences for scores compared to controls on VAN, (mean 0.4 vs 0.8, p = 0.07)., Conclusions: These results suggest that TAN, and possibly VAN, have potential for identifying misalignments in ocular position. After further technical development these tests might be useful in the future for screening patients in facilities that are not equipped to perform cervical and ocular vestibular evoked myogenic potentials.

With their essential role in inner ear function, stereocilia of sensory hair cells demonstrate the importance of cellular actin protrusions. Actin packing in stereocilia is mediated by cross-linkers of the plastin, fascin, and espin families. Although mice lacking espin (ESPN) have no vestibular or auditory function, we found that mice that either lacked plastin 1 (PLS1) or had nonfunctional fascin 2 (FSCN2) had reduced inner ear function, with double-mutant mice most strongly affected. Targeted mass spectrometry indicated that PLS1 was the most abundant cross-linker in vestibular stereocilia and the second most abundant protein overall; ESPN only accounted for ∼15% of the total cross-linkers in bundles. Mouse utricle stereocilia lacking PLS1 were shorter and thinner than wild-type stereocilia. Surprisingly, although wild-type stereocilia had random liquid packing of their actin filaments, stereocilia lacking PLS1 had orderly hexagonal packing. Although all three cross-linkers are required for stereocilia structure and function, PLS1 biases actin toward liquid packing, which allows stereocilia to grow to a greater diameter., (© 2016 Krey et al.)

There are a variety of techniques available to investigate endolymph dynamics, primarily seeking to understand the cause of endolymphatic hydrops. Here we have taken the novel approach of injecting, via a glass micropipette, fluorescein isothiocyanate-dextran (FITC-dex) and artificial endolymph into scala media of anaesthetized guinea pigs, with subsequent imaging of the inner ear using Light Sheet Fluorescence Microscopy (LSFM) as a means to obtain highly resolved 3D visualization of fluid movements. Our results demonstrate endolymph movement into the utricle, semicircular canals and endolymphatic duct and sac when more than 2.5 μl of fluid had been injected into scala media, with no apparent movement of fluid into the perilymphatic compartments. There was no movement of endolymph into these compartments when less than 2.5 μl was injected. The remarkable uptake of the FITC-dex into the endolymphatic duct, including an absorption into the periductal channels surrounding the endolymphatic duct, highlights the functional role this structure plays in endolymph volume regulation., (Crown Copyright © 2016. Published by Elsevier B.V. All rights reserved.)

Objective: The objective of this study was to explore the usefulness of 1000-Hz tone burst (TB) stimuli for detecting cervical vestibular-evoked myogenic potential (cVEMP) abnormalities in patients with a cochlear implant (CI)., Materials and Methods: Thirty asymptomatic patients who received unilateral CI because of severe bilateral sensorineural hearing loss were assessed for cVEMP produced by TB stimuli at two frequencies (500 and 1000 Hz) in the airway. VEMPs were recorded when the devices were switched to the on (CI-on) and off (CI-off) positions., Results: At the CI-on position, the surgical side (SS) 500-Hz response rates (15/30) were significantly higher than the SS 1000-Hz response rates (9/30) (p=0.031), while the non-operated control side (CS) 500-Hz response rates (20/30) were higher than the CS 1000-Hz response rates (18/30), but the difference was not significant (p=0.50). At the CI-on position, the SS 500-Hz response rates (15/30) were lower than the CS 500-Hz response rates (20/30), but the difference was not significant (p=0.063). However, the SS 1000-Hz response rates (9/30) were significantly lower than the CS 1000-Hz response rates (18/30) (p=0.004). When there was no significant difference between the 500-Hz amplitudes on either side, the SS 1000-Hz amplitudes were found to be significantly lower (p=0.04)., Conclusion: CIs have the potential to cause mechanical damage and electrical stimulation to the vestibular system. Possible implant-mediated mechanical damage and electrical stimulation in the high-frequency region affecting the cVEMP response could be found by a 1000-Hz stimulus.

Objective: To determine whether patients with acute unilateral peripheral vestibulopathy (PVP), often called "vestibular neuritis/neuronitis or neuropathy" (VN) have a vestibular lesion pattern consistent with the distribution of the neurological afferents., Background: Much is known about the clinical nature of PVP, however less so about its etiology and pathogenesis. Due to the frequency with which VN is used to describe the syndrome, an inflammation of the vestibular nerve or of one of its branches is often assumed to be the cause of PVP, though there is insufficient data so far to support this assumption., Methods: We conducted a retrospective study of 25 patients who had presented to our clinic with PVP and had all vestibular receptor organs tested shortly after start of symptoms. We analysed their vestibular lesion patterns in order to determine whether they were consistent with the neuritis hypothesis (NH)., Results: The lesion patterns varied conspicuously. 76% did not follow an innervation pattern, thereby contradicting the NH and only 24% had a lesion pattern that either definitely (16%) or probably (8%) supported the NH., Conclusion: These results should remind us to be careful before jumping to quick conclusions about the pathogenetic nature of PVP. With any reason to question VN as the only cause of PVP, we should reconsider the treatment approach to PVP. If the cause probably or even possibly lies inside the vestibular labyrinth, an intratympanic steroid injection might prove to be a more effective measure, even in first-line treatment. If the etiology is unsure, a combination of systemic and intratympanic steroid treatment may be adequate.

Background: It is well-known that ocular vestibular evoked myogenic potentials (oVEMPs) predominantly reflect utricular function whilst cervical vestibular evoked myogenic potentials (cVEMPs) reflect saccular function. To date, there are no published reports on the systemic evaluation of utricular and saccular function in benign paroxysmal positional vertigo (BPPV), nor are there any reports on the differences in VEMPs between patients with recurrent and non-recurrent BPPV. The aim of this study was to evaluate the difference in cervical and ocular (c/o)VEMPs between patients with BPPV and normal controls, as well as between patients with recurrent and non-recurrent BPPV., Methods: Thirty patients with posterior canal BPPV and 30 healthy subjects (as normal controls) were prospectively enrolled. cVEMP and oVEMP testing using 500 Hz tone-burst stimuli were performed on all. VEMP tests were repeated 3 times on each subject to ensure reliability and reproducibility of responses. VEMPs were defined as present or absent. Abnormal VEMP was defined by lack of VEMP response., Results: In the control group, abnormal cVEMPs responses were detected in 6.67% and abnormal oVEMPs responses were detected in 3.34%. In BPPV patients (10 with recurrent BPPV, 20 with non-recurrent BPPV), abnormal cVEMPs responses were detected in 30% and abnormal oVEMPs responses were detected in 56.7%. More patients with BPPV showed abnormal responses in c/oVEMPs as compared to the control group (p < 0.05). oVEMPs was more often abnormal as compared to cVEMPs in BPPV patients (p < 0.05). There was no statistical difference between abnormal cVEMP responses in non-recurrent BPPV patients (25%) and recurrent BPPV patients (40%) (p > 0.05). Differences in abnormal oVEMP responses (non-recurrent BPPV, 40%; recurrent BPPV, 90%) were significant (p < 0.05)., Conclusion: An increased occurrence of abnormal c/oVEMP recordings appeared in BPPV patients, possibly as a result of degeneration of the otolith macula. oVEMPs were more often abnormal in BPPV patients as compared to cVEMPs, suggesting that utricular dysfunction may be more common than saccular dysfunction. Furthermore, oVEMP abnormalities in the recurrent BPPV group were significantly higher than those in the non-recurrent BPPV group. Assessment of c/oVEMPs in BPPV patients may therefore be of prognostic value in predicting likelihood of BPPV recurrence.

Objectives: There is a high incidence of vestibular loss in children with cochlear implants (CCI). However, the relationship between vestibular loss and various outcomes is unknown in children. The objectives of this study are to (1) determine whether age-related changes in peripheral vestibular tests occur; (2) quantify peripheral vestibular function in children with normal hearing and CCI; and (3) determine whether amount of vestibular loss predicts visual acuity and balance performance., Design: Eleven CCI and 12 children with normal hearing completed the following tests of vestibular function: ocular and cervical vestibular-evoked myogenic potential to assess utricle and saccule function and the video head impulse test to assess semicircular canal function. The relationship between amount of vestibular loss and the following balance and visual acuity outcomes was assessed: dynamic gait index, single-leg stance, the sensory organization test, and tests of visual acuity, including dynamic visual acuity and the gaze stabilization test., Results: (1) There were no significant age-related changes in peripheral vestibular testing with the exception of the n23 cervical vestibular-evoked myogenic potential latency, which was moderately correlated with age. (2) CCI had significantly higher rates of vestibular loss for each test of canal and otolith function. (3) Amount of vestibular loss predicted performance on single-leg stance, the dynamic gait index, some conditions of the sensory organization test, and the dynamic visual acuity test. Age was also a contributing factor for predicting the performance of almost all outcomes., Conclusions: Preliminarily, children with vestibular loss do not recover naturally to levels of their healthy peers, particularly with activities that utilize vestibular input; they have poorer visual acuity and balance function.

Objective: To explore the roles of otolith organs in the occurrence and recurrence of primary benign paroxysmal positional vertigo (BPPV) by vestibular evoked myogenic potential (VEMP) test., Method: We enrolled 17 recurrent primary BPPV patients and 42 non-recurrent primary BPPV patients between September 2014 and November 2014. All patients underwent VEMP tests, including cervical vestibular evoked myogenic potential (cVEMP and ocular vestibular evoked myogenic potential (oVEMP) tests. The abnormal case was defined as non-elicitation or asymmetry rate between bilateral sides is larger than 29%., Result: Significant difference was found in abnormal rate between cVEMP and oVEMP (P < 0.05 ) in BPPV patients. The abnormal rate of oVEMP was higher than that of cVEMP. Significant difference was found in abnormal rate in oVEMP test between recurrent and non-recurrent groups (P < 0.01) but not in cVEMP( P > 0.05). No significant difference was found in sex and age between recurrent and non-recurrent groups (P > 0.05)., Conclusion: The impairment of otolith organs, especially the utricle, is related to primary BPPV. Dysfunction of utricle may play a role in recurrence of BPPV. Recurrence of BPPV is not correlated with sex and age.

Objectives: To assess the variability of normal values for cervical vestibular-evoked myogenic potentials (cVEMP) testing and to provide guidance regarding which parameters should be reported for clinical practice., Study Design: Forty-eight normal subjects with no history of hearing loss or vestibular symptoms underwent cVEMP testing. Measurement parameters were tabulated and compared to other sets of cVEMP normal values in the literature. The literature was reviewed to assess the clinical significance of abnormal cVEMP results. The distributions of threshold and symmetry ratios for normal subjects were compared to the distributions of 90 patients who underwent cVEMP testing., Setting: Tertiary academic center., Results: Upper limits of 42% symmetry ratio and the range of 65 to 95 dB HL for threshold were established for our center.The quartile coefficients of dispersion were much less than 1.0 for all cVEMP parameters in the literature, suggesting that the variability in normal ranges across the literature is small. The distributions for threshold and symmetry ratio were similar between normal and patient groups. There is a lack of information in the literature regarding the impairment of function resulting from various degrees of abnormality of VEMP results., Conclusions: Normal values for cVEMP parameters are statistically consistent in the literature. The clinical significance of abnormal values has not been validated. For clinical purposes, cVEMP "thresholds" should be reported. Reporting of other parameters is optional.

Objective: Previous observational studies suggest higher rates of vestibular dysfunction among patients with type 2 diabetes mellitus (DM) compared with those without diabetes. This study aims to functionally localize vestibular dysfunction in adults with type 2 DM., Study Design: Prospective cohort study., Setting: Tertiary academic medical center., Subjects and Methods: Adults 50 years of age and older with ≥10-year history of type 2 DM were recruited (December 2011-February 2013, n = 25). Vestibular function was assessed by cervical and ocular vestibular-evoked myogenic potentials (VEMPs), testing the saccule and utricle, respectively. Head thrust dynamic visual acuity testing assessed semicircular canal (SCC) function in all canal planes. Results were compared with nondiabetic age-matched controls (n = 25)., Results: Subjects were 64.7 ± 7.6 years old, were 40% female, and had a mean hemoglobin A1c of 8.3% ± 1.7%. SCC dysfunction was more common than otoconial organ dysfunction, with 70% of subjects with DM demonstrating impaired performance of at least 1 SCC (ΔlogMAR ≥0.18) and 50% demonstrating otoconial organ impairment (absent ocular VEMP and/or cervical VEMP). Adults with type 2 DM had poorer lateral and superior SCC performance (P < .05) but similar posterior SCC performance compared with controls (P = .16). Both cervical VEMP peak-to-peak amplitude and ocular VEMP n1 amplitude were also decreased with diabetes (P < .01)., Conclusion: Adults with type 2 DM have poorer performance on tests of vestibular function related to both SCC and otoconial organ function compared with nondiabetic age-matched adults. Future studies are needed to better understand the relationship between vestibular function and functional disability in persons with diabetes., (© American Academy of Otolaryngology—Head and Neck Surgery Foundation 2015.)

Objective: To investigate the diagnosis applying effects of ocular vestibular evoked myogenic potentials(oVEMP) in peripheral BPPV disease., Method: During September 2012 to January 2015, we selected 80 healthy people in our hospital medical center as the control group, choose the same period of primary benign paroxysmal positional vertigo as the observation group of 80 patients. Two groups were carried out fully functional auditory evoked potential analysis, determination of oVEMP and cervical vestibular evoked myogenic potentials (cVEMP) anomaly amplitude threshold, P1 latencies, N1 incubation period., Result: The cVEMP abnormal rate in the observation group was 28.8%, the oVEMP abnormal rate was 38.8%, while cVEMP and oVEMP abnormal rates in the control group was 1.3% and 2.5% respectively that compared to significant differences between the two groups (P < 0.05). The oVEMP test amplitude in the observation group was (5.98 ± 2.15) µv, the N1 incubation period was (10.03 ± 0.76)ms, while the control group were (4.09 ± 2.11)µv and (11.67 ± 0.78) ms that compared difference were statistically significant (P < 0.05). The cVEMP test amplitude in the observation group was (154.8 ± 43.9)2 µv, while the control group was (180.49 ± 45.34)µv, compared the difference was statistically significant (P < 0.05)., Conclusion: Paroxysmal positional vertigo patients ocular vestibular evoked myogenic potentials abnormal rate is relatively high, the utricle dysfunction for more severe than the balloon can be the subject of an objective function of the ear stone judgment, judgment in favor of the disease.

Objective: To investigate the extent of vestibular lesions in idiopathic sudden hearing loss (ISHL) with vertigo., Method: We reviewed the clinical records of 25 consecutive new patients with ISHL with vertigo. We classified patients based on their pattern of vestibular dysfunction. All patients showed cochlear damage and were labeled C (cochlear) type. If a patient showed abnormal cervical vestibular evoked myogenic potential (cVEMP), ocular VEMP (oVEMP) or caloric responses, an S (saccule), U (utricule) or L (lateral semicircular canal) respectively was added to their label., Results: All patients underwent cVEMPs and caloric tests. Sixteen (64%) and 13 (52%) showed abnormal cVEMPs and caloric responses, respectively, on the affected side. Among the 23 patients who underwent oVEMPs, 10 (43%) showed abnormal oVEMPs on the affected side. Of these 23 patients, 6 (26%) were classified as C type, 4 (17%) as CS type, 1 (4%) as CL type, 1 (4%) as CSU type, 2 (9%) as CSL type, 1 (4%) as CUL type, 8 (35%) as CSUL type., Conclusion: The vestibular end organs close to the cochlea tended to be preferentially affected., Significance: It is likely that vestibular dysfunction extends from organs close to the cochlea to those further from the cochlea., (Copyright © 2014 International Federation of Clinical Neurophysiology. Published by Elsevier Ireland Ltd. All rights reserved.)

Conclusions: Although combined utricular and canal paresis has been described previously, this is the first report of canal hyperactivity associated with utricular hypofunction. Unsteadiness and swaying were the most common symptoms, and patients with shorter duration of symptoms also had positional vertigo. We propose that this syndrome is a variant of utricular dysfunction and should be considered in the differential diagnosis of peripheral vestibular disorders., Objective: To describe a syndrome of instability associated with utricular dysfunction and hyperactive caloric responses., Methods: The study comprised 11 consecutive patients exhibiting abnormalities of the eccentric subjective visual vertical test (e-SVV) and high responses during the caloric test of the videonystagmography (VNG). We carried out a review of symptoms, physical examination, and vestibular tests., Results: There was no gender predilection or obvious etiology. The patients' main complaint included instability with linear symptoms (i.e., tilting, rocking, and swaying), with positional vertigo as a secondary symptom. Oculomotor testing, visual fixation index, and brain MRI were normal, excluding a central nervous system disorder. VNG was essentially normal except for hyperactive responses during the caloric testing in all patients. Abnormal e-SVV was found in 10 patients unilaterally and bilaterally in 1 patient. Abnormal oVEMP was found in seven of seven patients, further supporting a utricular site of lesion.

Objectives: Benign paroxysmal positional vertigo (BPPV) is a unilateral peripheral vestibular pathology, mostly involving the semicircular canals and the otolith organs. Although equivocal findings exist on the utility of cervical vestibular-evoked myogenic potential in identifying BPPV-associated changes in saccule, ocular vestibular-evoked myogenic potential (oVEMP), which is primarily a utricular response, has sparingly been explored in this population. Hence, the present study aimed at examining oVEMP in individuals with BPPV and comparing them with healthy individuals to illustrate its efficacy in identifying BPPV-associated changes in the utricle., Design: Using a case-control design, oVEMPs were elicited by 500 Hz tone bursts at 125 dB peak sound pressure level and recorded bilaterally from 30 individuals with unilateral posterior canal BPPV and 30 age- and gender-matched healthy controls., Results: There were no inter- or intragroup differences in latency aspects (p > 0.05); however, amplitudes were significantly smaller in BPPV ears compared with the non-BPPV ears of individuals with BPPV as well as ears of healthy controls (p < 0.05). Exceptions to this were five participants with BPPV in whom the affected ears demonstrated larger response amplitude (augmentation) than the unaffected ears. Furthermore, there was significantly larger interaural amplitude ratio in individuals with BPPV compared with the healthy controls (p < 0.05). Interaural amplitude ratio produced the largest effect size among the oVEMP parameters for differentiating BPPV from healthy controls., Conclusions: Large asymmetry ratio of oVEMP, usually exceeding 26.8%, is the most potent characteristic of oVEMP in BPPV. Abnormal oVEMP results confirm utricular pathology in ears with BPPV, and therefore, oVEMP can be used as an objective tool with asymmetry ratio as the parameter of choice for the evaluation of utricular function in persons with posterior canal BPPV.