Underwent cVEMP Testing Research Articles

Optimized Diagnostic Approach to Patients Suspected of Superior Semicircular Canal Dehiscence.

Current methods of diagnosing superior semicircular canal dehiscence syndrome (SCDS) include a clinical exam, audiometric testing, temporal bone computer tomography (CT) imaging, and vestibular evoked myogenic potential (VEMP) testing. The main objective of this study was to develop an improved diagnostic approach to SCDS optimized for accuracy, efficiency, and safety that utilizes clinical presentation, audiometric testing, CT imaging, high-frequency cervical VEMP (cVEMP) testing, and patient treatment preference. A secondary aim was to investigate the cost associated with the current versus proposed diagnostic paradigms. All patients who underwent cVEMP testing since introduction of the 2 kHz cVEMP in our clinical protocol in July 2018 were screened. Patients suspected of SCDS based upon symptoms who also had available audiogram, CT scan, and 2 kHz cVEMP were included (58 ears). Patients were categorized as dehiscent, thin, or not dehiscent based on their CT scan. Symptom prevalence and cVEMP outcomes were analyzed and compared for all groups. The accuracy of the 2 kHz cVEMP was calculated using CT imaging as the standard. Using a combination of patient symptomatology, audiometric, CT and 2 kHz cVEMP data, as well as patient preference, a best clinical practice approach was developed. The cost associated with this approach was calculated and compared with cost of the current SCDS diagnostic workup using Medicare reimbursement rates. In the overall patient population suspected of SCDS based on clinical presentation, the sensitivity and specificity of 2 kHz cVEMP were 76% and 100%, respectively, while the positive and negative predictive values were 100% and 84.6%, assuming that the CT scan finding was correct. Autophony was the most common symptom in patients who had both superior semicircular canal dehiscence on CT imaging plus abnormal 2 kHz cVEMP (p < 0.001). Combining patient symptomatology, 2 kHz normalized peak to peak cVEMP amplitude, and patient treatment preference to determine, which patients should undergo CT scanning resulted in a potential cost reduction between 45% and 61%. In patients suspected of SCDS based on their clinical presentation, the combination of symptomatology, 2 kHz cVEMP data, and patient preference can be used to determine which patients should undergo CT scanning, resulting in a diagnostic cost reduction and reduced patient radiation exposure.

Cervical Vestibular Evoked Myogenic Potentials That Are Absent at 500 Hz But Present at 1000 Hz Are Characteristic of Endolymphatic Hydrops-Related Disease.

It remains unclear whether the dominance of 1000 Hz responses over responses at 500 Hz in cervical vestibular evoked myogenic potentials (cVEMPs) are characteristic of endolymphatic hydrops (EH), due to the presence of patients with absent responses at both frequencies. The purpose of the present study is to examine whether the dominant cVEMP responses at 1000 Hz over 500 Hz are characteristic findings of EH-related diseases among patients who show various cVEMP findings. We retrospectively reviewed the medical records of 470 consecutive patients who underwent cVEMP testing with short-tone bursts at both 500 Hz and 1000 Hz. We categorized the cVEMP responses of these 470 patients into the following five groups: (group 1) present responses at both frequencies bilaterally, (group 2) present responses at 500 Hz but absent at 1000 Hz on at least one side, (group 3) absent responses at 500 Hz but present at 1000 Hz on at least one side, (group 4) absent responses at both frequencies on one side and present at both frequencies on the other side, and (group 5) absent responses at both frequencies bilaterally. We compared the proportion of EH-related diseases between each group and the other four groups and then investigated any increased or decreased disease incidence in each group. In group 3, the proportion of EH-related disease was significantly higher (p < 0.01), and the incidence of an EH-related disease was greatly increased (standard residual value > 3). cVEMPs that are absent at 500 Hz and present at 1000 Hz may be characteristic of EH-related disease.

Cervical vestibular evoked myogenic potentials in patients with the first episode of posterior canal benign paroxysmal positional vertigo before and after repositioning

Background Cervical vestibular evoked myogenic potentials (cVEMPs) are used to assess the sacculo-collic pathways. Benign paroxysmal positional vertigo (BPPV) is mainly a utricular disorder. Objectives To investigate cVEMPs in BPPV patients before and after repositioning maneuvers. Methods Forty patients with posterior canal BPPV with new onset symptoms underwent cVEMP testing at the time of diagnosis and a month after successful repositioning maneuver. p13, n23 latency and amplitude ratio values were compared with the results of 40 healthy controls. Results p13 and n23 latencies of the affected side were significantly longer than the healthy controls more prominent for the p13 latency. Comparison of the affected side with the non-affected side revealed delayed p13 latency on the affected side. Though a significant improvement in p13 latency was observed after repositioning, it was still prolonged when compared with the healthy controls. An abnormality regarding amplitudes was not present. Conclusions and significance cVEMP abnormalities in patients with BPPV indicate saccular dysfunction accompanying utricular dysfunction which seems to be confined to the symptomatic side at least in the early phase of the disease. Partial recovery can be seen after treatment with residual findings following even the first attack.

Predicting Development of Bilateral Menière's Disease Based on cVEMP Threshold and Tuning.

To investigate if the cervical vestibular evoked myogenic potential (cVEMP) is predictive for developing bilateral Menière's disease (MD). Retrospective cohort study. Tertiary care center. Records of 71 patients previously diagnosed with unilateral MD at our institution who underwent cVEMP testing between 2002 and 2011 were screened. Patients were contacted to answer a questionnaire to identify which patients had developed bilateral disease. Based on questionnaires and medical charts, 49 patients with a follow-up time of at least 5 years were included. The 49 originally asymptomatic ears are referred to as "study ears." Previously reported cVEMP criteria (original criteria) applied to study-ear cVEMPs separated them into Menière-like and normal-like groups. The main purpose was to determine if previously obtained cVEMP thresholds and tuning ratios of unilateral MD patients could predict who develops bilateral disease. From the 49 included patients, 12 developed bilateral disease (24.5%). The study ears characterized by original cVEMP criteria as Menière-like were significantly more likely to develop bilateral disease compared with the normal-like study ears. The original criteria predicted development of bilateral disease with a positive predictive value (PPV) and negative predictive value (NPV) of 58.3% and 86.5% respectively. ROC curves were used to revise cVEMP criteria for predicting the progression to bilateral disease. A revised criterion combining three cVEMP metrics, reached a PPV and NPV of 85.7% and 93.7%. cVEMP threshold and tuning in unilateral MD patients are predictive of which patients will develop bilateral disease.

Cervical VEMP tuning changes by Meniere's disease stages.

ObjectiveTo determine if changes in cervical vestibular‐evoked myogenic potential (cVEMP) testing reflect the different stages of cochlea‐saccular hydrops in Meniere's disease (MD).MethodsThis is a case‐control retrospective series. Forty‐seven patients with unilateral MD by American Academy of Otolaryngology–Head and Neck Surgery diagnostic and staging criteria, and 30 with non‐MD vertigo as control. Meniere patients were further classified based on symptoms at the time of testing as active or stable. Subsequently, patients underwent cVEMP testing by tone‐burst stimuli at 500 and 1,000 Hz. The main outcome measure was to compare the cVEMP 1,000 and 500 Hz amplitude ratio in ears with MD and non‐MD vertigo, and in active versus stable MD.ResultsThe cVEMP 1,000/500 Hz amplitude ratio was higher in Meniere's ears (mean = 1.14 μV, SD = 0.25) than in non‐Meniere's ears (mean = 0.96 μV, SD = 0.2) (Student's t test, P = .001), and higher in active (mean = 1.22 μV, SD = 0.25) than in stable MD (mean = 1.00 μV, SD = 0.18) (P = .0035). The diagnostic value of cVEMP 1,000/500 Hz amplitude ratio to differentiate MD versus non‐MD vertigo was evaluated with a receiver‐operating characteristics (ROC) curve and the area under the curve (AUC) was 0.716 (95% confidence interval [CI] [0.591, 0.829]). The ideal cutoff point was 0.9435 with sensitivity and specificity values of 83% and 53%, respectively. The sensitivity and specificity values for this test to differentiate active versus stable MD were 68% and 81%, respectively, with AUC 0.746 (95% CI [0.607, 0.885]) and cutoff value of 1.048. In all ears, the 1,000/500 Hz amplitude ratio increased by a decrease of the 500 Hz amplitude with increasing age.ConclusionThe cVEMP 1,000/500 Hz amplitude ratio is elevated in ears with MD but not in those with non‐MD vertigo. After corrected by age, this ratio is higher in active but not in stable MD, probably reflecting dynamic changes in saccular membrane motion mechanics in hydrops, and may be a useful marker of disease progression and the effect of therapy.Level of EvidenceIV

Toward Optimizing cVEMP: 2,000-Hz Tone Bursts Improve the Detection of Superior Canal Dehiscence

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.

Clinical utility of cervical vestibular-evoked myogenic potentials in predicting residual dizziness after benign paroxysmal positional vertigo

ObjectivesIn the present study, the value of cervical vestibular-evoked myogenic potential (cVEMP) as a predictive factor for residual dizziness after recovery of benign paroxysmal positional vertigo (BPPV) was evaluated. MethodsThe present study included 65 patients who had BPPV and underwent cVEMP testing. Patients were divided into two groups depending on the presence or absence of residual dizziness after recovery of BPPV. Univariate and multivariate analyses were performed to determine the factors associated with residual dizziness using age, gender, affected semicircular canal, affected side, BPPV duration, and cVEMP parameters. ResultsIn univariate analysis, cVEMP-modified interaural amplitude difference (IAD) ratio and p13 latency showed a relatively significant association (p < 0.20) with residual dizziness. Based on multivariate analysis, increased cVEMP-modified interaural amplitude difference (IAD) ratio at the affected side (≥25%; p = 0.018, OR 6.623) remained as an associated factor. ConclusionsIncreased cVEMP-modified IAD ratio at the affected side is associated with residual dizziness. BPPV patients with increased cVEMP-modified IAD ratio at the affected side are more likely to have residual dizziness after recovery of BPPV. SignificancecVEMP testing could be used for the prediction of residual dizziness. An increased cVEMP-modified IAD ratio at the affected side may be used as a predictor of residual dizziness.

Is Alteration of Tuning Property in Cervical Vestibular-Evoked Myogenic Potential Specific for Ménière’s Disease?

The aim of this study is to show sensitivity and specificity of cervical vestibular-evoked myogenic potential (cVEMP) tuning property test to Ménière's disease (MD) in comparison with healthy controls (HC) and patients with other vestibular diseases. Totally 92 subjects (50 women and 42 men, 20-77 years of age) were enrolled in this study. Subjects were composed of 38 definite unilateral MD patients, 11 unilateral benign paroxysmal positional vertigo patients, 14 vestibular migraine patients, 19 unilateral vestibular neuritis patients, and 10 HC. The subjects underwent cVEMP testing to 500 and 1,000 Hz short tone bursts (125 dBSPL). The corrected amplitudes of the first biphasic responses (p13-n23) (cVEMP) were measured. Then, a tuning property index (the 500-1,000 Hz cVEMP slope) was calculated. The area of under the ROC curve (AUC) was 0.75 in comparison with other vestibular disease patients, while AUC was 0.77 in comparison with other vestibular disease patients plus HC. The best cutoff point of the 500-1,000 Hz cVEMP slope was -19.9. Sensitivity of the tuning property test to MD was 0.74, while specificity was 0.76 to other vestibular disease patients. The tuning property test of cVEMP is useful as a screening test of MD.

Effect of personal music system use on sacculocollic reflex assessed by cervical vestibular-evoked myogenic potential: A preliminary investigation.

Listening to music through a portable personal music system (PMS) is a growing trend, especially among the youth. The preferred listening level in such kinds of PMS has been reported to cross the safe levels and its impact on the auditory system was demonstrated in several previous investigations. Owing to the commonality in several aspects between the auditory and the vestibular systems, it appears likely that the deleterious effects of PMS use could also be impinging on the vestibular system, which has never been investigated. The present study therefore, aimed at evaluating the effects of PMS use on the sacculocollic reflex assessed by the cervical vestibular-evoked myogenic potential (cVEMP) technique. Thirty-two regular PMS users and 32 nonregular PMS users underwent cVEMP testing using alternating polarity 500 Hz tone bursts. The results revealed no significant group difference in latencies and interaural asymmetry ratio. However, the cVEMP was significantly reduced in the group of individuals in whom the diffused field equivalent sound pressure levels (SPLs) were above the damage risk criteria (DRC) compared to those with diffused field equivalent SPLs below it (P < 0.01). Therefore, the use of PMS at high levels of volume controls could be deleterious to the vestibular well-being of an individual.

Normal Values for Cervical Vestibular-Evoked Myogenic Potentials.

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. 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. Tertiary academic center. 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. 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.

Frequency preference in cervical vestibular evoked myogenic potential of idiopathic otolithic vertigo patients. Does it reflect otolithic endolymphatic hydrops?

Conclusion: Idiopathic otolithic vertigo (IOV) with relatively long duration of attacks might be caused by endolymphatic hydrops in the otolith organ. Objectives: To clarify the pathophysiology underlying IOV, episodic tilting or translational sensation attacks by unknown causes, especially the possibility of endolymphatic hydrops in the otolith organ. Methods: Sixteen patients (6 men and 10 women) diagnosed with having IOV were enrolled. In these subjects, frequency preference in cervical vestibular evoked myogenic potential (cVEMP) was studied. The subjects underwent cVEMP testing using 500 Hz and 1000 Hz short tone bursts (STB) (125 dB SPL, air-conducted sound). The 500–1000 Hz cVEMP slope was calculated and assessed in comparison with data from healthy subjects in the preceding study. Results: Twelve of the 16 examined patients had a significant preference of 1000 Hz to 500 Hz, which was suggestive of endolymphatic hydrops in the saccule. Patients with frequency preference of 1000 Hz to 500 Hz showed a tendency for longer vertigo attacks than patients without preference of 1000 Hz.

Cervical vestibular evoked myogenic potentials (cVEMPs) in patients with superior canal dehiscence syndrome (SCDS)

Objective To determine the usefulness of both amplitude and threshold data from tone-burst cervical vestibular evoked myogenic potential (cVEMP) testing for the evaluation of superior canal dehiscence syndrome (SCDS). Study Design Case series with chart review. Subjects and Methods Sixty-seven patients underwent cVEMP testing. We correlated mean tone burst cVEMP amplitude and threshold data with temporal bone CT findings. Patients were excluded for Ménière's disease, middle ear disease, or otologic surgery. Results Superior canal dehiscence patients had higher mean cVEMP amplitudes (SCDS 173.8 μV vs non-SCDS 69.7 μV, P = 0.031) and lower mean thresholds (SCDS 72.8 dB nHL vs non-SCDS 80.9 dB nHL) at 500 Hz. Conclusion Patients with SCDS have larger amplitudes and lower thresholds on cVEMP testing at 500 Hz. This study supports the utility of tone burst cVEMPs for the evaluation of SCDS and is one of few large single-center studies to establish normative data.

CVEMP Testing in Patients with a Third Mobile Window

Objective To determine the usefulness of cervical vestibular-evoked auditory potential (cVEMP) testing for the evaluation of patients with and without a third mobile window (superior canal dehiscence or large vestibular aqueduct). Methods A retrospective review of charts from patients who underwent cVEMP testing at a single tertiary referral center was performed. The cVEMP is a vestibular reflex generated by an air-conducted stimuli, causing an inhibitory potential in the ipsilateral sternocleidomastoid muscle measured by external electrodes. cVEMP results were correlated with demographic characteristics, hearing testing, diagnosis, and imaging. Mean cVEMP thresholds (at 500 Hz) and amplitudes (@ 95dB nHL and 500 Hz) were compared between ears and between patients with and without a third mobile window (TMW). Unequal variance t-Test was used to determine significance. Patients were excluded if they had a history of Meniere's disease, middle ear disease or otologic surgery. Results 63 patients received cVEMP testing, of which 8 had either unilateral or bilateral TMW. 114 non-TMW ears were compared to 10 ears with TMW. Ears with TMW had a lower mean threshold (68 dB nHL) vs. non-TMW (83 dB nHL) (p&lt;0.003) and a higher mean amplitude (321?V) vs. non-TMW (78?V)(p&lt;0.009). Conclusions Patients with TMW have lower thresholds and higher amplitudes on cVEMP testing. This study supports the use of cVEMPs to diagnose TMW in patients who present with an unexplained air-bone gap, autophony, aural fullness, or dizziness.