Caloric Abnormalities Research Articles

Do measures of gain asymmetry and catch-up saccades improve video head impulse test agreement with caloric results?

ObjectiveTo investigate the relative sensitivity and agreement of caloric testing and video head impulse test (vHIT) across four groups of vestibular disorders. MethodsCaloric and vHIT results of 118 patients with either Ménière’s disease, vestibular neuritis/labyrinthitis, vestibular migraine, or vestibular schwannoma were retrospectively analyzed. vHIT gain, gain asymmetry, and catch-up-saccades (≥100°/sec) were compared with reference limits of 91 controls. ResultsAbnormal caloric results and vHIT gain were recorded in 57.6 % and 33.1 % of patients, respectively. Consideration of all three measures increased vHIT sensitivity to 43.2 %, and concordance with caloric results improved from 66.1 % to 70.3 %. A significant interaction effect confirmed the relationship between tests depended on the diagnosis (p = 0.013). Vestibular migraine and vestibular neuritis/labyrinthitis produced similar results on both tests, usually normal and abnormal respectively. Vestibular schwannoma produced more caloric abnormalities than vHIT gain but not compared with catch-up-saccades and gain asymmetry; Ménière’s disease produced more caloric abnormalities than all vHIT measures. When vHIT was normal (all measures), a 37 % canal paresis was 90 % specific for Ménière’s disease. ConclusionsRates of vHIT catch-up-saccades and gain asymmetry can improve sensitivity and concordance with caloric testing, but this is disease-dependent. SignificancevHIT outcome measures are complementary to the caloric test and each other.

Correlation between caloric test results and VHIT VOR gains in unilateral horizontal canal deficits: a cross-sectional study.

The purpose of the study is to evaluate the correlation between caloric test results and video head impulse test (VHIT) vestibulo-ocular reflex (VOR) gains in unilateral horizontal canal deficits in order to define a possible threshold value above which caloric deficits should be associated with predictable low VHIT VOR gains. Caloric test and VHIT were realised in 105 patients presenting with symptoms of rotational vertigo occurring within the last 2 weeks. The authors defined the cutoff value for a caloric abnormality as more than 15% of canal deficit, which allowed us to divide our patients on groups based on the severity of their caloric asymmetry. Then, the authors performed the VHIT considering abnormal horizontal gain as less than 0.8 with catch-up saccades. The authors evaluated the prevalence of results dissociation between the two tests and the correlation between the caloric asymmetry and the horizontal VHIT VOR gains in each group according to the severity of canal deficit. The correlation was considered statistically significant if P less than 0.05 (Fisher's exact test). The caloric test revealed a significant unilateral deficit in 50 patients (47.6%). The interval of deficit between 21 and 40% included 25 patients, 18 (72%) presenting with normal VHIT VOR gains versus 7. On the other hand, for the 12 patients in the intervals of 81-100% of deficit, the VHIT VOR gain was highly abnormal in all cases. In comparison with the normal caloric test group, a correlation between each interval of caloric deficits and VHIT VOR gains has been assessed. This correlation was significant in the interval of 41-60% (P=0.04 <0,05) and in the interval of 81-99% next to patients with a total deficit of 100% (P=0.006 <0.05 for each). It appears that simultaneous affection of high vestibular frequencies evaluated on VHIT may be more likely and predictable above a minimal threshold of 40% caloric asymmetry, with better discrimination between normal and abnormal VHIT above 80%. Thus, they are two complementary tests to use as a couple rather than a replacement one for the other.

Vestibular evaluation following cochlear implantation in patients with inner-ear anomalies.

This cross-sectional study investigated vestibular function outcomes after cochlear implantation in patients with inner-ear anomalies. Twenty-two patients with bilateral symmetric inner-ear anomalies and 28 patients with normal inner ears were included. All were congenitally or progressively deaf persons implanted unilaterally during the previous 15 years. Vestibular system function was assessed by vestibular-evoked myogenic potential and bithermal caloric tests. The vestibular-evoked myogenic potential abnormality rate in implanted ears with an inner-ear anomaly was 81.8 per cent, compared with 39.3 per cent in implanted ears with normal anatomy. In the non-implanted sides, the rate was 45.5 per cent (10 out of 22 cases) in the inner-ear anomaly patients compared with 17.9 per cent in patients with normal inner-ear structure. The respective abnormal caloric test rates in inner-ear anomaly versus normal anatomy patients were 81.8 per cent and 17.9 per cent (implanted ears), 77.3 per cent and 14.3 per cent (non-implanted sides). Inner-ear anomaly and implantation were both associated with more vestibular-evoked myogenic potential abnormalities; when occurring together, these factors showed a synergistic effect. Caloric test abnormality is mainly dependent on the presence of an inner-ear anomaly, but implantation is not associated with caloric abnormality.

Age-related Patterns of Vestibular Dysfunction in Dizziness and Imbalance: A Review of Vestibular Testing Results Among 1,116 Patients.

To characterize differences in vestibular testing results among patients presenting with balance-related complaints; to stratify patterns of testing abnormalities by age. Retrospective chart review. Academic Balance Center at a Tertiary Referral Center. All patients who underwent vestibular testing in a 1-year period from 2017 to 2018. Balance function test results. We reviewed 1,116 patients with age ranging from 11 to 94 years, including 521 patients ≥60 years. Most patients had at least 1 abnormal result, with only 21% of patients ≥60 years and 43% of patients <60 years yielding no test abnormalities (p < 0.001). Among 754 individuals with abnormal testing results, caloric testing did not show any significant difference between age groups. Patients ≥60 years of age were more likely to demonstrate abnormalities on saccadic and horizontal tracking eye movements (p < 0.01; sacc 20.8% vs 6.3%; HT 9.2% vs 4.7%), as well as positional and Dix-Hallpike testing with videonystagmography (p < 0.001; pos 52.3% vs 37.5%, DH 14.4% vs 6.8%). On computerized dynamic posturography, there were significantly more abnormal composite scores in the older group for both sensory organization and motor control testing (p < 0.001; SOT 31.8% vs 8.8%, MCT 7.6% vs 1.8%). Among patients presenting balance-related complaints, a majority demonstrate at least one abnormality on vestibular testing. While caloric abnormalities occur across the life span, patients ≥60 years of age are more likely to have abnormal results in random saccades, positional, Dix-Hallpike testing, and posturography, with greater effect sizes in tests of central function. While the causes of imbalance and vertigo remain multifactorial, vestibular dysfunction can be considered a major contributor to balance dysfunction in the elderly population and should be thoroughly evaluated.

Comparisons among vestibular examinations and symptoms of vertigo in sudden sensorineural hearing loss patients.

Vertigo in sudden sensorineural hearing loss (SSNHL) is hypothesized as an extension of the disease caused by the anatomical proximity of the cochlea and vestibule. The present study aimed to demonstrate the association of vestibular function test (VFT) results with SSNHL disease severity and prognosis. This study assessed clinical records of 263 SSNHL patients admitted to our hospital, between January 2010 and October 2017. Steroid treatment comprised high-dose intravenous dexamethasone (16mg/d) or oral methylprednisolone (64mg/d) for 4days and tapered oral methylprednisolone for 8days after discharge. Caloric tests were performed in all patients, and cervical vestibular-evoked myogenic potential (c-VEMP) and ocular VEMP (o-VEMP) tests were performed in 209 and 144 patients, respectively. Ninety six patients had vertigo, and caloric abnormalities were observed in 119 patients. Initial PTA in patients with vertigo were worse than in those without vertigo (63.0dB vs 72.7dB, P=.002). Initial PTA in patients with abnormal o-VEMP was worse than in those with normal o-VEMP (61.4dB vs 73.0dB, P=.004). PTA improvement after steroid treatment in patients with vertigo was lower than in those without vertigo (25.0dB vs 20.9dB, P=.028). PTA improvement after treatment in patients with abnormal caloric results was lower than in those with normal caloric results (26.0dB vs 18.4dB, P=.013). The functions of vestibular organs, particularly the utricle and lateral semicircular canal, are associated with disease severity and hearing outcome in SSNHL patients.

Lying-down nystagmus and head-bending nystagmus in horizontal semicircular canal benign paroxysmal positional vertigo: are they useful for lateralization?

BackgroundLateralization of horizontal semicircular canal benign paroxysmal positional vertigo (HSC-BPPV) is very important for successful repositioning. The directions of lying-down nystagmus (LDN) and head-bending nystagmus (HBN) have been used as ancillary findings to identify the affected sites. This retrospective study was performed to evaluate the lateralizing values of LDN and HBN using clinical and laboratory findings for lateralizing probabilities in patients with HSC-BPPV.MethodsFor 50 HSC-BPPV patients with asymmetric direction-changing horizontal nystagmus (DCHN) during the head-rolling test (HRT) using Frenzel goggles, the directions of LDN and HBN were evaluated and compared to those determined by video-oculography. Directional LDN was defined as the contralesional direction of nystagmus in geotropic types and the ipsilesional direction in apogeotropic types. Directional HBN was defined as the opposite direction relative to directional LDN. We also analyzed LDN and HBN in 14 patients with a history of ipsilesional peripheral vestibulopathy, caloric abnormality or conversion from other types of BPPV (such as probable localized HSC-BPPV, pro-BPPV).ResultsLDN and HBN were seen in 68% (34/50) and 76% (38/50) of patients, respectively. Of these, 19 (55.9%), and 28 (73.7%) patients showed directional LDN and HBN, respectively. The proportion of patients with directional LDN and HBN was much smaller among the pro-BPPV patients (4/12 for LDN, 3/10 for HBN).ConclusionsLDN and HBN did not seem to predict lateralization in patients with HSC-BPPV. To improve the prediction of lateralization of HSC-BPPV, it is necessary to modify the maneuvers used to elicit LDN or HBN, especially in cases of symmetric DCHN during HRT.

Evaluation of Vestibular Function in Idiopathic Sudden Sensorineural Hearing Loss

Background and Objectives : It is very important to evaluate vestibular function in patients with sudden sensorineural hearing loss (SNHL) because vertigo combined with sudden SNHL is well known as an important prognostic factor. However, the vestibular function test is not usually performed in sudden SNHL patients without vertigo. We investigated whether different vestibular function tests such as the results of vestibular evoked myogenic potential (VEMP) testing or caloric testing were correlated to prognosis in not only sudden SNHL patients with vertigo but also in sudden SNHL patients without vertigo. Subjects and Method : We enrolled in our study 47 patients with idiopathic sudden SNHL with vertigo or without vertigo. The degree of initial hearing loss was categorized as mild, moderate, moderate-severe, severe, and profound group. Types of initial audiograms were categorized as high tone loss, low tone loss, flat and scale out type. We analyzed the association of the VEMP and caloric test with degree of hearing loss, type of audiogram, and hearing recovery in two month. Results : The more sever the hearing loss was, the more increased was the rate of abnormal VEMP response (p=0.003). The rate VEMP and caloric abnormality was higher in hearing loss types with high tone loss than in the types with only low tone loss. The rate of accompanying vertigo was high (p=0.017), when the hearing loss was more severe. There was significant correlation between the hearing recovery and vestibular dysfunction (p=0.000, r=0.563). Conclusion : VEMP and caloric test are useful in evaluating vestibular function and prognosis of sudden SNHL patients.

Comparison of vestibular function between large cerebellopontine angle meningioma and schwannoma

Conclusion. Abnormal caloric and vestibular evoked myogenic potential (VEMP) responses are frequently encountered with a large cerebellopontine angle (CPA) schwannoma, while normal caloric responses and abnormal VEMPs are noted with a large CPA meningioma. This difference may possibly exist because schwannoma causes vestibular deficits via parenchymal involvement, while vestibular deficits in the meningioma are mostly due to compression neuropathy. Objectives. This study aimed to compare the tumor characteristics in relation to vestibular function, i.e. caloric and VEMP responses, between large-sized (>2.5 cm) meningioma and schwannoma in the CPA. Patients and methods. Five patients with large CPA meningioma and nine patients with large CPA schwannoma were enrolled in this study. Each patient underwent a battery of tests including audiometry, caloric test, VEMP test, and MRI study. Results. The meningioma group showed 20% caloric abnormality and 75% VEMP abnormality, while the schwannoma group revealed 100% caloric and 100% VEMP abnormalities. A significant difference existed in relation to caloric abnormality between the two groups, but not in relation to VEMP abnormality.

Using Swaystar to measure sway amplitude in an office setting.

The study was conducted to determine if Swaystar (University Hospital, Basel), a device that measures trunk sway, could be used in the office to detect abnormalities in patients who had vestibular abnormalities. Prospective study design. Patients were referred to our tertiary and quaternary care dizziness clinic. We measured total sway amplitudes using Swaystar during tandem walking of 18 patients referred sequentially who were identified as abnormal by caloric testing. These patients were compared with age- and sex-matched subjects from our normative Swaystar databank. We measured total sway amplitude in pitch and roll planes with Swaystar during tandem walking testing with eyes open and eyes closed. Patients with caloric abnormalities had significantly higher total sway than the age- and sex-matched normals from our normative databank. Swaystar is sensitive to measuring increased sway amplitude in patients with balance system deficits (as documented by caloric abnormalities) whether the patient is unstable in the pitch plane, roll plane, or both.

The phenotype of DFNA13/COL11A2: nonsyndromic autosomal dominant mid-frequency and high-frequency sensorineural hearing impairment.

To study nonsyndromic progressive sensorineural hearing impairment in patients with a COL11A2 mutation (DFNA13) in a Dutch kindred. Survey. Department of otorhinolaryngology of a university hospital. Twenty-one living members of a Dutch family (150 relatives in 5 generations; 49 were studied) with autosomal dominant nonsyndromic sensorineural hearing impairment showed linkage to the DFNA13 locus. Mutation analysis revealed a missense mutation in the COL11A2 gene. History was taken, hearing threshold levels were measured in all affected persons, and penetrance was evaluated. Longitudinal analysis (using linear regression analysis of threshold-on-age data) was possible in only 1 case. Cross-sectional analysis comprised the comparison of threshold levels between different generations of the family. Also, hearing thresholds were corrected for median presbyacusis to find out whether the hearing impairment characteristic of this trait is stationary or progressive. Vestibular functions were evaluated with electronystagmography, by use of rotatory and caloric tests. Most of the affected persons dated their first hearing impairment symptoms to the second to third decade of life. A possibly reduced penetrance was found. Anamnestically, 4 affected persons had hearing impairment symptoms from early childhood onward. Longitudinal analysis in the proband (IV26) revealed the exceptional combination of congenital offset and substantial early progression. Most of the threshold levels differed significantly between the frequencies within each age group and, at the high frequencies (2-8 kHz), between the two age groups covered by generations IV and III (ages 30-38 years and 58-74 years, respectively); the latter could be attributed to presbyacusis. Various caloric abnormalities, including areflexia, were found in about half (8/17) of the tested subjects with sensorineural hearing impairment. Correction for age, hearing impairment-presumably present and stationary from an early age onward-showed the worst or second-worst threshold usually at 1, 2, and 6 kHz (3540 dB) or 8 kHz (50 dB), whereas the best or second-best threshold was found at 0.25 to 0.5 and 4 kHz (25 dB). Presbyacusis, presumably from the fourth decade of life onward, caused a change of the typically shaped audiogram described as midfrequency hearing impairment with additional high-frequency impairment.

頭振後眼振検査の臨床的検討

The clinical efficacy of head shaking nystagmus (HSN) were studied in 170 patients complaining of vertigo, dizziness or hearing loss. The over all provocation rate of HSN was 69% (117/170), which was much higher than that of spontaneous, positional or positioning nystagmus. Even in patients tested long after a vertigo attack, HSN was easily provoked. In the majority (95%) of the patients with caloric abnormality, the deficiency type of HSN (briskly beating nystagmus immediately after head shaking) towards the contralateral side of canal paresis (CP) was observed. The number of nystagmus beats increased as head shaking continued. These results suggest that HSN is provoked by the accumulation of dominant stimulation to the normal lateral semicircular canal.

Dynamic Posturography and Caloric Test Results Patients with and without Vertigo

Patients with dizziness were evaluated with caloric stimulation and with dynamic platform posturography (Neurocom Equitest). The ability of these tests to detect abnormalities in patients with and without vertigo was assessed. In 159 patients, roughly a third had abnormal calorics while half experienced one or more "falls" during posturography. Calorics revealed proportionately more abnormalities in patients with vertigo, whereas posturography alone did not distinguish between patients with or without vertigo. Posturography did, however, identify abnormalities in a third of patients with normal calorics, regardless of their history of vertigo. Overall, more patients with vertigo had at least one abnormal test result (70%) compared with patients without vertigo (47%). We conclude that caloric abnormalities correlate with a history of vertigo, whereas posturographic deficits can be identified regardless of the presence of vertigo.

眼振誘発法としての頭振り検査の再検討 ＩＩ 患側診断的意義について

The head-shaking test provokes effectively a latent spontaneous vestibular nystagmus (head-shaking nystagmus). The diagnostic significance of head-shaking nystagmus for the site of lesion was studied on 191 patients who visited our otologic clinic from 1980 to 1982 with complaints of dizziness.1. In 78.7% of the patients of unilateral lesion, the nystagmus was directed contralateral to the site of lesion, and in 21.3%, ipsilateral.2. In 79.3% of the patients of unilateral hearing loss, the nystagmus was directed contralateral to the site of hearing loss, and in 20.7%, ipsilateral.3. In 96.7% of the patients with caloric abnormality, the nystagmus was directed contralateral to the site of canal paresis (CP), and in 3.3%, ipsilateral.In 4 patients with directional preponderance (DP), the nystagmus had the same direction as DP.4. The head-shaking nystagmus, which is directed contralateral to the site of lesion, the site of hearing loss, or the site of CP, is considered as the deficiency nystagmus, while the nystagmus, which is directed ipsilateral, is considered as the recovery nystagmus. The both types of nystagmus can be distinguished from their styles of beating.5. The biphasic nystagmus was observed in 9 patients with peripheral lesions. The 1st phase was considered to be the deficiency nystagmus, and 2nd phase, recovery nystagmus.

Vestibular function tests in children.

Vestibular function tests were performed on a series of 57 children between the ages of 1 and 16 years. Inattention and immaturity of eye movement control created difficulties in the analysis of the electronystagmography traces in some instances. With the eyes closed, spontaneous and positional nystagmus occurred in 20% of asymptomatic children and this was thought to be physiological. Changes in external ear pressure (fistula test) enhanced this spontaneous nystagmus. Smooth pursuit ataxia and optokinetic abnormalities were common in the children with reading disabilities and those with congenital deafness, and were thought to be soft neurological signs of brainstem dysfunction. The torsion swing chair test was acceptable and gave easily readable responses. Caloric abnormalities were very common in children with reading disabilities and provided useful information in those with congenital and acquired disorders of hearing and balance. It was concluded that normal data were required for children of all ages in order to improve our understanding of electronystagmography in children.

Measurements of ocular countertorsion reflex with fundoscopic camera in normal subjects and in patients with inner ear lesions.

To record the ocular countertorsion reflex (OCR), we devised a new technique using an ophthalmo-fundoscope camera. OCR was measured in twenty two healthy subjects and in eighty three patients with inner ear lesions as benign paroxysmal positional vertigo (BPPV), sudden deafness, Meniere's disease, vestibular neuronopathy, acoustic neuroma and cases given ototoxic drugs. The mean values and the standard deviations of OCR for healthy subjects were obtained, but a wide range of the values in each eye in each direction was evident. Considering the wide range of OCR values, judgement should based not only on OCR value itself, but on differences in OCR values between clockwise (CW) and counter-clockwise (CCW) tilt or on the percentage of OCR values in CW or CCW tilt to the total countertorsion of that eye. In this report OCR values below 2∘ in either tilt (CW or CCW) were regarded as abnormal and 5∘ differences at 30∘ tilt and 4∘ differences at 45∘ tilt between CW and CCW tilt were regarded as suspicious of otolith dysfunction. Abnormal OCR values in most unilateral inner ear lesions excluding acoustic neuromas were seen in 14% according to our criteria. The incidence of abnormal OCR values was high in BPPV with caloric abnormalities, acoustic neuromas and in cases given ototoxic drugs, while it was less in BPPV without caloric abnormalities and vestibular neuronopathy. From the results obtained by this test, a hypothesis was drawn as to the relation of the tilt to the lesion of the otolith organ. With the development of the otolith function test, it could be applied to many disorders of the inner ear and internal auditory canals and to reevaluate the hitherto known diagnosis as Meniere's disease, sudden deafness etc.

Cochleo-vestibular involvement in otosclerosis.

A clinical analysis was carried out upon 202 otosclerotic patients. As the age of patients increased there was a parallel increase of deafness and the latter was accompanied by a greater cochleo-vestibular involvement. Those ears with cochlear involvement showed a greater percentage of caloric abnormalities than the ears with a purely conductive deafness. Fifty-six patients (27.7%) had vestibular symptomatology and in this group there was no correlation between either age, deafness or severity of symptoms. It is concluded that in the course of time the otosclerotic lesions cause a progressive involvement of both cochlear and vestibular capsules thus producing lesions of the sensori-neural elements in the anterior and posterior labyrinths. The vestibular involvement may explain the presence of vertiginous crises in at least some of the patients.