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International Journal of Clinical & Experimental Otolaryngology (IJCEO)    IJCEO-2572-732X-03-001e

Peripheral Vestibular Evaluation - A New Horizon


Doettl SM

Associate Professor, The University of Tennessee Health Science Center, College of Health Professions, Department of Audiology and Speech Pathology, Knoxville, TN, USA.

*Corresponding Author

Steven M. Doettl, Au.D., CCC-A,
Associate Professor, The University of Tennessee Health Science Center,
College of Health Professions, Department of Audiology and Speech Pathology,
Knoxville, TN 37996, USA
E-mail: sdoettl@uthsc.edu

Received: June 15, 2017; Published: June 21, 2017

Citation: Doettl SM (2017) Peripheral Vestibular Evaluation - A New Horizon. Int J Clin Exp Otolaryngol. 3(1e), 1-3. doi: dx.doi.org/10.19070/2572-732X-170002e

Copyright: Doettl SM© 2017. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited.



Vertigo, imbalance, and dizziness are reported with a 1-year prevalence in the adult population of 48.3%, 39.1%, and 35.6% respectively [1]. Falls in the elderly represent 2.8 million emergency departments visits each year [2]. Reportedly, 5-8% of children will experience vertigo in the general population [3-5]. These statistics exemplify a significant public health issue with significant implications across populations. There is universal agreement that any investigation for reported vertigo, imbalance, and dizziness begins with a thorough medical evaluation. Regardless of the patient population or presenting symptoms it is imperative to firstdetermine if any acute or chronic underlying medical conditions exist. This is, of course, not a simple task as the sheer number of possible pathologies resulting in vertigo, dizziness, and imbalance is daunting.

Often, quantitative evaluations can be quite valuable in guiding medical management decisions. Peripheral vestibular evaluation specifically can provide quantitative information as part of the overall medical evaluation for patients reporting vertigo, dizziness, and/or imbalance. Electronystagmography (ENG), videonystagmography (VNG) and rotary chair testing (RCT) comprise a typical peripheral vestibular evaluation. Electrophysiologic measures such as auditory brainstem response (ABR) and electrocochleography (ECOG) may also be useful in the evaluation of select peripheral vestibular disorders. These protocols, in the absence of additional techniques, provide information about peripheral vestibular function and in many cases, prove effective and efficient. Of course, these techniques also have inherent challenges that can limit their overall effectiveness across a wide range of populations in both the clinic and in the scientific community.

When assessing for peripheral vestibular hypofunction, either to confirm or rule out dysfunction, ENG/VNG and RCT only assess the horizontal semicircular canals (SCCs) and the superior division of vestibular nerve of the VIII cranial nerve. Additionally, caloric irrigation is an evaluation of non-physiologic low-frequency stimulation of the horizontal SCCs with RCT representing lowto mid-frequency stimulation. Neither caloric irrigation or RCT provide high-frequency stimulation. ABR evaluations can be quite valid for use in assessing patients for acoustic neuroma/ vestibular schwannoma (AN/VS), however imaging studies can also confirm AN/VS and it is exceedingly rare, reported to occur with 19 tumors per million per annually [6]. ECOG testing, used specifically in cases of suspected Meniere’s disease (MD), can be technically challenging and has been reported, when usingextra tympanic measurement, to have poor sensitivity (71%), and especially in the early symptomatic period [7, 8]. When positive findings suggesting peripheral vestibular dysfunction are noted using these techniques they are quite valuable to proper diagnoses and management. However, due to the above noted factors these tests with negative findings for peripheral vestibular dysfunction can result in false negative findings and/or the inability toconfidently rule-out dysfunction.

Peripheral vestibular evaluation technology has advanced, improving the ability to fully assess the peripheral vestibular system. Specifically, Video Head Impulse Testing (VHIT) and Vestibular Evoked Myogenic Potentials (VEMPs) have been added to the vestibular test battery. These tests have expanded the available information to include high-frequency stimulation, the function of the posterior SCCs, anterior SCCs, inferior division of the vestibular nerve of the VIII cranial nerve, the saccule, and the utricle. These tests combined with the traditional vestibular test battery allow for a more complete peripheral vestibular evaluation to either confirm peripheral dysfunction or rule-out vestibular involvement.

The VHIT utilizes video-oculography to allow for recording and detailed analysis of the vestibular-ocular reflex (VOR) for gain and catch-up saccades with high-frequency stimulation for all 6 semicircular canals independently [9-11]. VHIT provides the only clinically available method for assessing the posterior and anterior SCCs in a quantitative manner. VEMP evaluations (cervical and ocular) provide an evaluation of saccule and the inferior division of the vestibular nerve of the VIII cranial nerve and utricle andsuperior division of the vestibular nerve of the VIII cranial nerve function using the electrophysiologic evaluation of the vestibulospinal and vestibulo-ocular reflexes, [12-15]. VEMP testing provides the only clinically available methods for assessing the otolithic organs in a quantitative manner. Additionally, VEMP testing has proved quite useful for the assessment of specific peripheral vestibular dysfunction and other dysfunction such as superior canal dehiscence, enlarged vestibular aqueduct, vestibular migraines, and MD [16-18].

It is important to note that both VHIT and VEMP, like traditional vestibular evaluation techniques, have their own limitations. VHIT testing has lower sensitivity than caloric testing, but higher specificity when assessing the horizontal SCCs [19, 20]. Both cVEMPs and oVEMPs have well-documented age-effects and can be difficult to obtain in older patients [21, 22]. VEMPs also have varied sensitivity and specificity to different peripheral vestibular pathologies [23]. It is the combination of VNG, RCT, ABR, ECOG, VHIT, cVEMP, and oVEMP results that can now provide information regarding each of the 10 sensory structures of the peripheral vestibular system as well as the inferior and superior divisions of the vestibular nerves at a wide spectrum of stimulation and disorders.

In addition, the ability to assess the vestibular structures through a wider variety of techniques now also allows for expanded clinical and research populations. RCT testing is not commonly available and caloric testing is often poorly tolerated leading to the common practice that children under the age of 6 were not testable. VHIT testing has been validated for use down to 3 years of age [24, 25]. cVEMPs and oVEMPs have been observed and measurable in neonates with modified techniques [26-28]. VEMPs specifically, have been integral in identifying an expanded population at elevated risk for vestibular dysfunction.

Several specific disorders such as CHARGE and Usher syndrome have been well-known to present with vestibular deficits; however, the occurrence of vestibular deficits with other types of hearing loss has not been extensively described. Recent research utilizing combination techniques to assess vestibular function in children with hearing loss have suggested 70-85% of children with hearing loss across etiologies demonstrate vestibular abnormalities on one or more of the currently available vestibular tests [29-32]. The new techniques combined with additional advances with traditional vestibular evaluation such handicap inventories and oculomotor testing have also helped to expand the diagnostic assessment and capabilities in the pediatric population [33-35].

Current peripheral vestibular techniques including ENG/VNG, RCT, ABR, ECOG, VHIT, cVEMPs, and oVEMPs allow for further investigation of vestibular function and improved ability to confirm or rule-out peripheral vestibular dysfunction in wider range of populations making for a new horizon in both the clinic and scientific communities. These techniques can help provide efficient and comprehensive management in patients with reported vertigo, imbalance, and/or dizziness with the goals of minimizing office visits, reducing the risk of falls, and providing proper identification and management of children with vestibular dysfunction as well as expanding the available scientific evidence across populations, disorders, and function.


References

  1. Bisdorff A, Bosser G, Guegeun R, Perris P (2013) The epidemiology of vertigo, dizziness, and unsteadiness and its links to co-morbidities. Front Neurol. 4(29): 1-7.
  2. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web–based Injury Statistics Query and Reporting System (WISQARS) [online]. June 12, 2017.
  3. Humphriss R, Hall A (2011) Dizziness in 10-year-old children: an epidemiological study. Int J Ped Otorhinolaryngol. 75(3): 395-400.
  4. Lee JD, Kim CH, Hong SM, Kim SH, Suh MW, et al., (2017) Prevalence of vestibular and balance disorders in children and adolescents according to age: A multi-center study. Int J Ped Otorhinolaryngol. 94: 36-39.
  5. Li CM, Hoffman HJ, Ward BK, Cohen HS, Rine RM (2016) Epidemiology of dizziness and balance problems in children in the United States: A population based study. J Pediatr. 171(1): 240-247.
  6. Stangerup SE, Tos M, Thomsen J, Caye-Thomasen P (2010) True incidence of vestibular schwannoma?. Neurosurg. 67(5): 1335-1340.
  7. Chung WH, Cho DY, Choi JY, Hong SH (2004) Clinical usefulness of extratympanic electrocochleography in the diagnosis of Meniere’s disease. Otol Neurotol. 25(2): 144-149.
  8. Oh KH, Kim KW, Chang J, Jun HS, Kwon EH, et al., (2014) Can we use electrocochleography as a clinical tool in the diagnosis of Meniere’s disease during the early symptomatic period?. Acta Oto-laryngol. 134(8): 771-775.
  9. Weber KP, MacDougall HG, Halmagyi GM, Curthoys IS (2009) Impulsive testing of semicircular‐canal function using video-oculography. Ann New York Acad Sci. 1164(1): 486-491.
  10. MacDougall HG, Weber KP, McGarvie LA, Halmagyi GM, Curthoys IS (2009) The video head impulse test Diagnostic accuracy in peripheral vestibulopathy. Neurol. 73(14): 1134-1141.
  11. Macdougall HG, McGarvie LA, Halmagyi GM, Curthoys IS, Weber KP (2013) The Video Head Impulse Test (vHIT) detects vertical semicircular canal dysfunction. PLoS One. 8(4): e61488.
  12. Colebatch JG, Halmagyi GM (1992) Vestibular evoked potentials in human neck muscles before and after unilateral vestibular deafferentation. Neurol. 42(8): 1635-1636.
  13. Colebatch JG, Halmagyi GM, Skuse NF (1994) Myogenic potentials generated by a click-evoked vestibulocollic reflex. J Neuro Neurosurg Psych. 57(2): 190-197.
  14. Todd NP, Rosengren SM, Aw ST, Colebatch JG (2007) Ocular vestibular evoked myogenic potentials (OVEMPs) produced by air-and bone-conducted sound. Clin Neurophys. 1189(2): 381-390.
  15. Curthoys IS, Vulovic V, Manzari L (2012) Ocular vestibular-evoked myogenic potential (oVEMP) to test utricular function: neural and oculomotor evidence. Acta Otorhinolaryngol Ital. 32(1): 41.
  16. Zuniga MG, Janky KL, Nguyen KD, Welgampola MS, Carey JP (2013) Ocular vs. cervical VEMPs in the diagnosis of superior semicircular canal dehiscence syndrome. Otol Neurotol. 34(1): 121.
  17. Taylor RL, Bradshaw AP, Magnussen JS, Gibson WP, Halmagyi GM, et al., (2012) Augmented ocular vestibular evoked myogenic potentials to airconducted sound in large vestibular aqueduct syndrome. Ear Hear. 33(6): 768-771.
  18. Taylor RL, Zagami AS, Gibson WP, Black DA, Watson SR, et al., (2012) Vestibular evoked myogenic potentials to sound and vibration: characteristics in vestibular migraine that enable separation from Meniere’s disease. Cephalalgia. 32(3): 213-225.
  19. McCaslin DL, Jacobson GP, Bennett ML, Gruenwald JM, Green AP (2014) Predictive properties of the video head impulse test: measures of caloric symmetry and self-report dizziness handicap. Ear Hear. 35(5): e185-e191.
  20. Janky K, Shepard N (2009) Vestibular evoked myogenic potential (VEMP) testing: normative threshold response curves and effects of age. J Am Acad Audiol. 20(8): 514-522.
  21. Rosengren SM, Govender S, Colebatch JG (2011) Ocular and cervical vestibular evoked myogenic potentials produced by air-and bone-conducted stimuli: comparative properties and effects of age. Clin Neurophys. 122(11): 2282-2289.
  22. Brantberg K (2009) Vestibular evoked myogenic potentials (VEMPs): usefulness in clinical neurotology. Sem Neuro. 29(5): 541-547.
  23. Bartolomeo M, Biboulet R, Pierre G, Mondain M, Uziel A, et al., (2014) Value of the video head impulse test in assessing vestibular deficits following vestibular neuritis. Eur Arch Oto-Rhino-Laryngol. 271(4): 681-688.
  24. Hamilton SS, Guangwei Z, Brodsky JR (2015) Video head impulse testing (VHIT) in the pediatric population. Int J Ped. Otorhinolaryngol. 79(8): 1283-1287.
  25. Hülse R, Hörmann K, Servais JJ, Hülse M, Wenzel A (2015) Clinical experience with video Head Impulse Test in children. Int J Ped Otorhinolaryngol. 79(8): 1288-1293.
  26. Sheykholesami K, Kaga K, Megerian CA, Arnold JE (2005) Vestibular- Evoked Myogenic Potentials in Infancy and Early Childhood. Laryngoscope. 115(8): 1440-1444.
  27. Erbek S, Erbek SS, Gokmen Z, Ozkiraz S, Tarcan A, et al., (2007) Clinical application of vestibular evoked myogenic potentials in healthy newborns. Int J Ped Otorhinolaryngol. 71(8): 1181-1185.
  28. Hsu YS, Wang SJ, Young YH (2009) Ocular vestibular-evoked myogenic potentials in children using air conducted sound stimulation. Clin Neurophys. 120(7): 1381-1385.
  29. Zagólski O (2007) Vestibular system in infants with hereditary nonsyndromic deafness. Otol Neurotol. 28(8): 1053-1055.
  30. Shinjo Y, Jin Y, Kaga K (2007) Assessment of vestibular function of infants and children with congenital and acquired deafness using the ice-water caloric test, rotational chair test and vestibular-evoked myogenic potential recording. Acta Oto-laryngol. 127(7): 736-747.
  31. Kaga K, Shinjo Y, Jin Y, Takegoshi H (2008) Vestibular failure in children with congenital deafness. Int J Audiol. 47(9): 590-599.
  32. Emami SF, Farahani F (2015) Saccular dysfunction in children with sensorineural hearing loss and auditory neuropathy/auditory dys-synchrony. Acta Oto-laryngol. 135(12): 1298-1303.
  33. McCaslin DL, Jacobson GP, Lambert W, English LN, Kemph AJ (2015) The development of the vanderbilt pediatric dizziness handicap inventory for patient caregivers (DHI-PC). Int J Ped Otorhinolaryngol. 79(10): 1662-1666.
  34. Doettl SM, Plyler PN, McCaslin DL, Schay NL (2015) Pediatric Oculomotor Findings during Monocular Videonystagmography: A Developmental Study. J Am Acad Audiol. 26(8): 703-715.
  35. Doettl SM, Plyler PN, McCaslin DL (2017) Artifact in Pediatric Oculomotor Findings during Videonystagmography: A Retrospective Analysis. J Am Acad Audio. 28(4): 314-324.

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