Peripheral Vestibular Lesions Research Articles

Congenital Cholesteatoma of Petrous Apex – case report and review of literature

Objective: Congenital cholesteatomas of the petrous apex are rare lesions that develop insidiously, which delays diagnosis and requires a high index of suspicion. A case report of supralabyrinthine congenital petrous bone cholesteatoma and review of recent literature are presented. Methods: A 27-year-old woman presented with progressive facial palsy. Otomicroscopy did not reveal any abnormalities, and hearing was normal. Although there were no complaints of vertigo or instability, vestibular examinations indicated a non-compensated peripheral vestibular lesion. Radiological examinations revealed a lesion in the petrous apex and epitympanum that had features of a cholesteatoma. Results: To preserve normal hearing, the middle fossa approach was chosen for surgery. A damaged part of the facial nerve was reconstructed with cable graft. Conclusion: Advances in radiological imaging facilitate surgical planning, and improvements in the techniques of lateral skull base surgery enable safe and radical removal of petrous bone cholesteatomas with minimal morbidity.

Diagnosis, treatment, and rehabilitation in patients with dizziness and cognitive impairment

Complaints of dizziness and instability are the common reason for seeking a neurologist's advice at an outpatient visit and can be the frequent reason for emergency hospitalization. Difficulty in diagnosing the causes of dizziness and instability is due to a diversity of diseases manifested by these symptoms. The list of etiological factors includes peripheral and central vestibular lesions and unrelated nervous system diseases. In a number of cases, dizziness and instability are concurrent with cognitive impairment. Complaints of poor concentration and memory, dizziness and instability can often be associated with brain degenerative and/or vascular lesions, as well as with pathological mood changes and anxiety disorder. The diagnosis of these diseases requires neurovestibular examination, cognitive testing, and assessment of the emotional status of patients. Early detection of the causes of dizziness and memory disorders ensures better treatment results. There are different approaches to therapy for dizziness and cognitive impairment: drug and non-drug correction techniques (vestibular rehabilitation and cognitive training). Biofeedback procedures were shown to be highly effective. The effect of tanakan in treating patients with involvement of the peripheral vestibular system and brain structures is discussed

Peripheral vestibular syndrome. Etiologic differential diagnosis algorithm and therapeutic recommendations

Peripheral vestibular syndrome is frequently met in daily ENT practice (30% of patients). History and bedside exa­mination are crucial un differentiating peripheral and central vestibular lesions, as in establishing the ae­tio­logy whenever possible. This paper presents a dif­ferential diagnostic algorithm for vertiginous syn­drome, a specific category of the vestibular lesions, in which clinical presentation is dominated by VERTIGO. It also presents appropriate treatment options for each aetiology. Bimodal treatment - medication (betahystine) and customised vestibular rehabilitation programs - aims to facilitate the physiologic vestibular central com­pen­sation process. This will enable more rapid and more complete recovery of the unilateral vestibular lesion.

Diagnosis and current therapy of vestibular syndromes

Vertigo and dizziness are with an annual incidence of more than 10% and a lifetime prevalence of more than 30% among the most frequent symptoms. The keys to the diagnosis are the patient history and the bedside examination: a) for the patient history the time course, type and triggers of symptoms and accompanying symptoms, b) for the clinical examination of the vestibular system the head-impulse test (HIT), the examination for a spontaneous nystagmus, a displacement of subjective visual vertical, a positional nystagmus and the Romberg test, and c) for the differentiation between an acute peripheral and central vestibular lesion the skew deviation, central fixation nystagmus, gaze-evoked nystagmus, saccadic smooth pursuit and a normal HIT. The various forms of vertigo are treated with pharmacological therapy, physical therapy, psychotherapeutic measures and, rarely, surgery. For pharmacotherapy there are basically eight groups of drugs that can be used: anti-emetics, -inflammatory, -menières, -migraineous medications, anti-depressants, -convulsants, aminopyridines and acetyl-DL-leucine, however, with a currently often low level of evidence.

Predictors of central vestibular disorders from videonystagmography tests

Abstract The diagnosis of central vestibular lesion is challenging and sometimes there is an overlap in symptoms and signs with a peripheral vestibular lesion. In some selected cases, dizziness is the only presenting symptom and in other patients, mild neurological symptoms as numbness are ignored. Videonystagmography (VNG) is considered a useful method for diagnosing vertigo of peripheral origin; however, not all the patients with central vertigo can be diagnosed easily. Benign paroxysmal positional vertigo and central positional vertigo share common criteria. The aim of the present study is to assess the usefulness of different VNG tests as predictors of central vestibular disorders, to determine the criteria that differentiate central positional nystagmus from the peripheral type, and to attempt to relate the abnormality in different VNG tests to certain central nervous system (CNS) levels. A retrospective study was carried out on 51 patients with possible central vestibular disorders from VNG tests battery and were referred for an MRI for further assessment. According to MRI results, the patients were divided into group A (31 patients), the group with manifest MRI findings, and group B, the group with free MRI (20 patients). Different VNG tests were compared between both groups. Three predictors of CNS lesion by VNG were determined: fixation index (FI), oculomotor tests, and central positional nystagmus; there was a statistically significant difference between both groups in FI, oculomotor tests, and central positional nystagmus, and apogeotropic criteria or nystagmus in multiple plains. There was no relation between any of those predictors and specific levels in the CNS. VNG tests are a good diagnostic tool to differentiate between peripheral and central vestibular lesions. The inclusion of FI and positional tests to the oculomotor tests increases the sensitivity of the VNG. In some cases, it is difficult to distinguish between benign paroxysmal positional vertigo and central positional vertigo; apogeotropic nystagmus and nystagmus in multiple plains should raise the suspicion of CNS lesion. Anterior circulation ischemia may lead to chronic vertigo symptoms. Central vestibular vertigo could be caused by dysfunction or excitation of various structures in the CNS including the vestibular cortex.

Modified head shake sensory organization test: Sensitivity and specificity

The Sensory Organization Test (SOT) of Computerized Dynamic Posturography (EquiTest™ equipment) is a valuable tool for investigating how an individual uses balance system sensory input (vestibular, vision, proprioception/somatosensory) to maintain quiet stance; however, it is limited as a screening tool for identifying peripheral vestibular system dysfunction. Previous research has shown that adding horizontal head-shake to portions of the standard SOT battery improved the identification of peripheral vestibular system asymmetry; however, flaws in the methods were noted. The objective of this work was to evaluate the sensitivity and specificity of the modified head-shake SOT (HS-SOT) protocol for identification of peripheral vestibular system lesion. Fifteen patients with chief complaint of instability, vertigo, and/or lightheadedness, with and without a caloric unilateral weakness (UW) and fifteen age-matched healthy controls were included in the final analysis. Ten of the 15 patients demonstrated a caloric UW≥25%. Participants completed standard conditions 2 and 5 of SOT with head still and during four horizontal head-shaking tasks (i.e., HS-SOT2-60°/s, HS-SOT2-120°/s, HS-SOT5-15°/s, and HS-SOT5-60°/s). Average equilibrium scores decreased as condition difficulty increased (SOT2, HS-SOT2-60°/s, HS-SOT2-120°/s, SOT 5, HS-SOT5-15°/s, and HS-SOT5-60°/s) for each group; as expected, a lower decline was noted for controls (slope=−6.59) compared to patients (slope=−11.69). The HS-SOT5-15°/s condition was superior for identifying peripheral vestibular asymmetry (AUC=0.90 sensitivity=70%, specificity=100%), with the strongest correlation to caloric UW% (rs=−0.743, p=0.000006). HS-SOT5-15°/s appears to be a promising screening measure for peripheral vestibular asymmetry.

Vestibular Compensation in Unilateral Patients Often Causes Both Gain and Time Constant Asymmetries in the VOR.

The vestibulo-ocular reflex (VOR) is essential in our daily life to stabilize retinal images during head movements. Balanced vestibular functionality secures optimal reflex performance which otherwise can be distorted by peripheral vestibular lesions. Luckily, vestibular compensation in different neuronal sites restores VOR function to some extent over time. Studying vestibular compensation gives insight into the possible mechanisms for plasticity in the brain. In this work, novel experimental analysis tools are employed to reevaluate the VOR characteristics following unilateral vestibular lesions and compensation. Our results suggest that following vestibular lesions, asymmetric performance of the VOR is not only limited to its gain. Vestibular compensation also causes asymmetric dynamics, i.e., different time constants for the VOR during leftward or rightward passive head rotation. Potential mechanisms for these experimental observations are provided using simulation studies.

Cortical aspects of balance and spatial orientation

Spatial orientation (“am I upright?”) and postural control (“I must stand upright”) are closely linked. Human disease often disturbs both processes simultaneously, either by interfering with one of the critical sensory inputs (vestibular, visual, proprioceptive) or the CNS integrative processes. Part of this central integration is responsible for the process of “sensory re-weighting” which, among other functions, allows clinical recovery following peripheral sensory deficits. The more common of these is an acute peripheral vestibular lesion, in which case we say that recovery is mediated by “central vestibular compensation”. In this lecture, rather than discussing eye movements recovery in vestibular lesions, we will focus on compensation of perceptual and orientation functions. We will see how vestibular perception undergoes a shut-down process which may be viewed as a central anti-vertiginous mechanism [1] and how long term symptomatic recovery can be predicted on the basis of a simple perceptual assessment of “visual dependence” [2] , that is, how much “weight” a person places on visual input (as opposed to vestibular) for spatial orientation. We will touch on a clinical and research tool, the subjective visual vertical (SVV), to illustrate via patients’ examples the critical role played by tactile cues in setting the SVV [3] and dispel the myth that the SVV is a selective test of otolith function [4] . Finally, we will touch upon the central integrative processes and show how visuo-spatial and vestibular functions are lateralised to the right hemisphere, accounting for the interesting “pusher” syndrome in right parietal strokes [5] and for co-lateralisation of handedness and vestibular function [6] .

Modifications of perineuronal nets and remodelling of excitatory and inhibitory afferents during vestibular compensation in the adult mouse.

Perineuronal nets (PNNs) are aggregates of extracellular matrix molecules surrounding several types of neurons in the adult CNS, which contribute to stabilising neuronal connections. Interestingly, a reduction of PNN number and staining intensity has been observed in conditions associated with plasticity in the adult brain. However, it is not known whether spontaneous PNN changes are functional to plasticity and repair after injury. To address this issue, we investigated PNN expression in the vestibular nuclei of the adult mouse during vestibular compensation, namely the resolution of motor deficits resulting from a unilateral peripheral vestibular lesion. After unilateral labyrinthectomy, we found that PNN number and staining intensity were strongly attenuated in the lateral vestibular nucleus on both sides, in parallel with remodelling of excitatory and inhibitory afferents. Moreover, PNNs were completely restored when vestibular deficits of the mice were abated. Interestingly, in mice with genetically reduced PNNs, vestibular compensation was accelerated. Overall, these results strongly suggest that temporal tuning of PNN expression may be crucial for vestibular compensation.

Role of cervical vestibular-evoked myogenic potentials testing in vestibular migraine

BackgroundVestibular dysfunction has been long described in patients with migraine; this relation has been addressed as vestibular migraine. The pathophysiology as well as the peripheral or central localization of this deficit is unclear. Cervical vestibular evoked myogenic potential (cVEMP) is a validated method to test saccular function and vestibulocollic pathway. ObjectivesThe current work was designed to assess the characteristics of cVEMP response in patients with vestibular migraine and compare them with the results of healthy controls, and to find out if the cVEMP could be useful as a complementary tool for testing vestibular function in vestibular migraine. MethodsTwenty five patients with definite vestibular migraine were involved as a study group. Twenty healthy volunteers of comparable age and sex were taken as a control group. The amplitude and latency of cVEMP were measured. Electronystagmography (ENG) test battery including caloric testing was done. ResultsOur study demonstrated significant reduction in cVEMP amplitudes, and more frequently absent response in patients with vestibular migraine compared to healthy controls. There was no correlation between cVEMP amplitudes and caloric testing. ENG tests showed peripheral vestibular lesion in 36% of patients, central lesion in 16%, mixed lesion in 4%. ConclusioncVEMP is a useful complementary tool for testing vestibular function in vestibular migraine. Reduced cVEMP amplitude or absent response were the most frequent features in vestibular migraine. The saccule and or the sacculo-collic pathway are affected in vestibular migraine, with more tendencies for peripheral vestibular dysfunction in our patient group.

Inner ear deficits in irradiated nasopharyngeal carcinoma survivors.

Despite the advancement of concurrent chemoradiotherapy, inner ear symptoms such as hearing loss, tinnitus, or vertigo/dizziness are still experienced in irradiated nasopharyngeal carcinoma (NPC) survivors. This study utilized an inner ear test battery to assess the causes and sequence of inner ear deficits in irradiated NPC survivors with a mean interval of 10 years after radiotherapy. Retrospective study. Thirty-six irradiated NPC survivors were enrolled. Otoscopy and an inner ear test battery comprising audiometry were performed, as well as ocular vestibular-evoked myogenic potential (oVEMP), cervical VEMP (cVEMP), and caloric tests. Otoscopic examination revealed middle ear complications in 37 ears (51%), including radiation-induced otitis media in 32 ears and otitis media with effusion in five ears. Percentages of abnormal cVEMP test, oVEMP test, bone-conducted mean hearing level, and caloric test were 91%, 75%, 67%, and 39%, respectively, exhibiting a significantly declining sequence in inner ear deficits. Most (67%) NPC survivors had inner ear deficit originated from peripheral vestibular lesion, mainly due to sequela of otitis media. In contrast, 33% of them had inner ear deficit caused by central vestibular disorder. A significant sequential decline in inner ear function of irradiated NPC survivors was observed from the saccule to the utricle, cochlea, and semicircular canals. Most of them were due to sequela of otitis media, followed by central vestibular disorder. 4.

Rotational chair testing in patients with unilateral peripheral vestibular disorders

Abstract The aim of the study was to evaluate the rotational chair (RC) sinusoidal harmonic acceleration (SHA) test and the rotational velocity step (RVS) test in patients with unilateral peripheral vestibular disorders. This study was retrospective in nature. It was conducted in a clinical tertiary care vestibular function test center. A total of 119 patients (63 men and 56 women) with documented unilateral peripheral vestibular lesions were evaluated with bithermal binaural caloric and sinusoidal and step velocity RC tests. Clinical, caloric, and RC tests were carried out. The study group was selected by including patients with a clinical diagnosis suggestive of peripheral vestibular lesions and with documented unilateral caloric weakness matching the clinical diagnosis, and by excluding patients with a clinical diagnosis suggestive of a peripheral vestibular lesion but not documented by unilateral caloric weakness, as well as patients with incomplete tests or uninterpretable data (due to poor recordings or eye movement artifacts). Caloric testing was performed using an infrared video-oculographic system and a Brookler-Grams closed-loop irrigation unit with standard bithermal irrigations of 30 and 44°C for 45 s each in the following order: L30°C, R30°C, R44°C, and L44°C. The RC testing paradigms used in this study were the rotational SHA test and the RVS test. When patients were classified on the basis of etiology, the most common cause of dizziness in the study group was found to be Mιniθre’s disease (34.9%), followed by vestibular neuritis (31.1%). Seventy-two patients in the study group demonstrated right caloric weakness and 47 patients demonstrated left caloric weakness, whereas only 18 of 119 patients demonstrated directional preponderance. When the RC SHA test parameters (gain, phase, and symmetry) in the study group were compared with the manufacturer’s normal values, statistically significant difference was seen in vestibulo-ocular reflex (VOR) gain at low frequencies (0.01-0.08 Hz), in VOR phase at all frequencies, and in VOR symmetry at low frequencies (0.01-0.04 Hz). In summary, despite the encouraging results of the discriminating power of caloric testing, it should be emphasized that RC testing has its own unique capabilities, such as the following: (i) it is a physiologic stimulus whose frequency and amplitude can be varied precisely; (ii) the stimulus is unrelated to physical features of the external ear or temporal bone; (iii) it is useful in children who may not tolerate caloric testing; and (iv) it is very useful in assessing patients receiving vestibulotoxic drugs. Multiple stimuli of varying intensities can be applied to the vestibular system within a relatively short period of time.

Role of electronystagmography in balance disorders: A clinical study

Aim and Objectives: To evaluate the role of electronystagmography (ENG) in the diagnosis of balance disorders, to localize the level of lesion in cases of vertigo, and to classify the etiology into peripheral and central causes. Materials and Methods: This study included 120 patients who presented with primary complaints of vertigo or dizziness. The inclusion criteria were all patients with complaints of vertigo with satisfactory vision. All patients underwent a thorough examination and appropriate investigations. Patients were subjected to ENG under optimal conditions and the results were obtained in the form of a butterfly chart after analysis of the ENG data. Results and Observations: Of the 120 patients subjected to ENG, we found that half the patients who presented with complaints of dizziness turned up as normal. 39 patients (33%) were diagnosed with peripheral vestibular lesion whereas 17% showed a central lesion of the vestibular system. The presence of a vestibular lesion was confirmed by performing a Dix-Hallpike maneuver. This returned a positive result in 33% of the cases. Canal paresis and directional preponderance, which were taken as the parameters of our study were analyzed in detail and significant correlation between the two was found. For higher values of directional preponderance, the canal weakness assumed greater significance. Conclusion: ENG has proven to be a useful first-line investigation in the diagnosis of vertigo. It can also act as a useful screening tool to differentiate between classical vertigo and other causes of the disequilibrium. It has special significance in localizing the side of the lesion which is especially useful in the further management of disorders like benign paroxysmal positional vertigo.

外側半規管型良性発作性頭位めまい症

Lateral semicircular canal benign paroxysmal positional vertigo reveals atypically direction changing positional nystagmus (geotropic and apogeotropic). Furthermore, this condition used to be recognized as the clinical sign of posterior cranial fossa lesions, in particular, lesions of the brainstem and cerebellum. On the other hand, a good number of clinical reports indicate, nowadays, that such positional nystagmus is more likely to be caused by peripheral vestibular lesions and this has become widely well-known. For instance, geotropic direction changing positional nystagmus is caused by canalolithiasis and apogeotropic direction changing nystagmus is associated with cupulolithiasis. Some textbooks argue whether or not such positional nystagmus could represent central nervous system findings and signs, and this still remains controversial. We therefore tried to examine states of nystagmus based on a review of clinical papers and deliberate the clinical significance and diagnostic value of nystagmus. Base on the results of our literature research we were unable to determine whether or not nystagmus findings could suggest central nervous system lesions. We concluded that, notwithstanding direction changing positional nystagmus, the best approach would be to consider each situation again from the beginning, taking the patient's present history in greater detail and performing neurological and neuro-otological examinations on each patient, which could provide the most important information to doctors regarding dizzy patients.

The role of videonystagmography (VNG) in assessment of dizzy patient

Videonystagmography (VNG) is a complete diagnostic system for recording, analyzing, and reporting eye movements using video imaging technology, in which hi-tech video goggles with infrared cameras are used. VNG includes a series of tests used to determine whether a vestibular disease may be causing a balance or dizziness problem; VNG can differentiate between a central and a peripheral vestibular lesion, and, if peripheral, it can decipher between unilateral and bilateral vestibular loss. VNG addresses the functionality of each ear.

Vestibular assessment: a practical approach

This paper presents an evidence-based introduction to assessing and managing the dizzy patient. It is based upon a literature review highlighting current best practice and the clinical experience of the author. Dizziness is common, often chronic and largely untreated, resulting in great personal and economic loss. Serious pathological causes of dizziness may be quickly and effectively screened by a simple ocular motor examination, differentiating these from peripheral vestibular lesions. A triage, differentiating dizziness into either acute onset, intermittent episodes or continuous symptoms is proposed, along with management strategies for the commonest causes of dizziness. Vestibular suppressant medication should be restricted to the acute phase of a vestibular episode. Vestibular rehabilitation therapy is the most effective treatment for continuous or chronic dizziness.

Periodic alternating nystagmus of peripheral vestibular origin

Periodic alternating nystagmus (PAN) is most commonly found either in its congenital form or after cerebellar/pontomedullary lesions. However, we identified PAN in 10 patients with peripheral vestibular disorders and will try to describe their characteristics to aid in the differential diagnosis between peripheral and central etiologies. Observation of a case series. Peripheral vestibular lesions were confirmed by neurological examinations, vestibular function tests, and brain magnetic resonance imaging (MRIs). Eye movements of the patients were recorded using electronystagmography or video nystagmography for a minimum of 10 minutes to confirm the nystagmus change in direction. The final diagnoses of the patients included Meniere's disease (n = 3), acute labyrinthitis (n = 4), sudden sensorineural hearing loss with vertigo (n = 2), and vestibular schwannoma (n = 1). Direction-changing spontaneous horizontal nystagmus with quiescent intervals was observed in all patients under dark conditions. The nystagmus was suppressed by visual fixation; and the results of oculomotor tests were normal for saccadic and smooth pursuit eye movements and optokinetic nystagmus. All patients showed mild to complete canal paresis on a bithermal caloric test. PAN progressed into unidirectional nystagmus of the contra-lesion side in all patients within 48 hours. PAN can be observed in patients with peripheral vestibular disorders, but detecting PAN in this subpopulation is difficult because of its transitory nature. The absence of central symptoms and signs, the visual suppression of PAN, normal oculomotor tests, and transient persistence are important diagnostic clues for differentiating peripheral from central PAN. 4.

Changes in Histamine Receptors (H1, H2, and H3) Expression in Rat Medial Vestibular Nucleus and Flocculus after Unilateral Labyrinthectomy: Histamine Receptors in Vestibular Compensation

Vestibular compensation is the process of behavioral recovery following peripheral vestibular lesion. In clinics, the histaminergic medicine is the most widely prescribed for the treatment of vertigo and motion sickness, however, the molecular mechanisms by which histamine modulates vestibular function remain unclear. During recovery from the lesion, the modulation of histamine receptors in the medial vestibular nucleus (MVN) and the flocculus may play an important role. Here with the means of quantitative real-time PCR, western blotting and immunohistochemistry, we studied the expression of histamine receptors (H1, H2, and H3) in the bilateral MVN and the flocculus of rats on the 1st, 3rd, and 7th day following unilateral labyrinthectomy (UL). Our results have shown that on the ipsi-lesional flocculus the H1, H2 and H3 receptors mRNA and the protein increased significantly on the 1st and 3rd day, with compare of sham controls and as well the contralateral side of UL. However, on the 7th day after UL, this expression returned to basal levels. Furthermore, elevated mRNA and protein levels of H1, H2 and H3 receptors were observed in the ipsi-lesional MVN on the 1st day after UL compared with sham controls and as well the contralateral side of UL. However, this asymmetric expression was absent by the 3rd post-UL. Our findings suggest that the upregulation of histamine receptors in the MVN and the flocculus may contribute to rebalancing the spontaneous discharge in bilateral MVN neurons during vestibular compensation.

Restricted Neural Plasticity in Vestibulospinal Pathways after Unilateral Labyrinthectomy as the Origin for Scoliotic Deformations

Adolescent idiopathic scoliosis in humans is often associated with vestibulomotor deficits. Compatible with a vestibular origin, scoliotic deformations were provoked in adult Xenopus frogs by unilateral labyrinthectomy (UL) at larval stages. The aquatic ecophysiology and absence of body-weight-supporting limb proprioceptive signals in amphibian tadpoles as a potential sensory substitute after UL might be the cause for a persistent asymmetric descending vestibulospinal activity. Therefore, peripheral vestibular lesions in larval Xenopus were used to reveal the morphophysiological alterations at the cellular and network levels. As a result, spinal motor nerves that were modulated by the previously intact side before UL remained permanently silent during natural vestibular stimulation after the lesion. In addition, retrograde tracing of descending pathways revealed a loss of vestibular neurons on the ipsilesional side with crossed vestibulospinal projections. This loss facilitated a general mass imbalance in descending premotor activity and a permanent asymmetric motor drive to the axial musculature. Therefore, we propose that the persistent asymmetric contraction of trunk muscles exerts a constant, uncompensated differential mechanical pull on bilateral skeletal elements that enforces a distortion of the soft cartilaginous skeletal elements and bone shapes. This ultimately provokes severe scoliotic deformations during ontogenetic development similar to the human syndrome.

Audiovestibular manifestations in a radiologically confirmed enlarged vestibular aqueduct in congenital nonsyndromic sensorineural hearing loss in Egypt

EnAbstract Background Enlarged vestibular aqueduct (EVA), the most common radiological finding in children with sensorineural hearing loss, is associated with variable auditory and vestibular symptoms. Aim of the work The aim of this study was to determine vestibular findings in patients with EVA. Patients and methods Twenty patients diagnosed with sensorineural hearing loss and EVA were included in the study group and 20 healthy individuals matched for age and sex were included in the control group. Both groups were subjected to the following: complete history taking, general and neurological examination, full ENT examination, pure tone audiometry, tymanometry, high-resolution computed tomography, vestibular evoked myogenic potentials (VEMP), caloric test, and computerized dynamic posturography. Results EVA was bilateral in 14 patients and unilateral in six patients. The VEMP amplitude of wave p13–n23 was higher in ears with EVA and it correlated positively with its size. p13–n23 latencies did not differ significantly from the control group. The caloric test showed an absent response in four patients, unilateral weakness in six patients, and normal results in 10 patients. There was no statistically significant difference in the results of computerized dynamic posturography. Conclusion The results showed a larger VEMP amplitude, which is indicative of a third window lesion. Some patients showed abnormalities in the caloric test, which indicates a peripheral vestibular lesion. VEMP, caloric test, and computerized dynamic posturography testing were effective in the evaluation of patients with EVA.