Vestibular Clinic Research Articles

Translation and Validation of the Dizziness Handicap Inventory into Thai Language.

To translate and evaluate psychometric properties of Thai version of the Dizziness Handicap Inventory (DHI-TH). A cross-sectional study. Ambulatory. Fifty patients with dizziness at a vestibular clinic. Translation and cross-cultural adaptation of the original English version of the DHI was performed according to published guidelines. Psychometric evaluation included internal consistency, content validity, test-retest reliability, convergent validity, discriminant ability, and responsiveness. Responsiveness was examined in 28 patients with vestibular dysfunction who received vestibular rehabilitation for 6 to 8 weeks. There were no floor and ceiling effects. The Cronbach's alpha was good for the total score (0.87) and subscale scores (0.70 physical, 0.73 emotional, and 0.71 functional). Excellent test-retest reliability was demonstrated for the total and subscales (ICC ranged from 0.91 to 0.97, p < 0.001). The SEM was 3.50 and the MDC was 9.68. The total and subscales of DHI-TH were moderately correlated with the SF-36-TH scores (r ranged from -0.40 to -0.63). An optimal cut-off point for detection of dizziness was 21 points (98% sensitivity, 94% specificity). Responsiveness of the DHI-TH was excellent. The ES and SRM were large (1.25 and 1.59, respectively). The DHI-TH discriminated well between patients with self-perceived improved dizziness versus unchanged dizziness (AUC = 0.87). The MCID was 17 points (82.0% sensitivity, 82.0% specificity). The DHI-TH demonstrated good psychometric properties for patients with dizziness. The DHI-TH is a valid and reliable instrument recommended as a measure of disability and quality of life in Thai patients with dizziness.

The fixation suppression test can uncover vertical nystagmus of central origin in some patients with dizziness.

Identifying dangerous causes of dizziness is a challenging task for neurologists, as it requires interpretation of subtle bedside exam findings, which become even more subtle with time. Nystagmus can be instrumental in differentiating peripheral from central vestibular disorders. Conventional teaching is that peripheral vestibular nystagmus is accentuated by removal of visual fixation. We sought to systematically test the hypothesis that, in some cases, vertical nystagmus due to central vestibular disorders may also be easier to identify when fixation is removed. To identify patients with vertical nystagmus, we retrospectively reviewed clinical, MRI, and VNG data of consecutive patients undergoing VNG in our vestibular clinic over a 9-month period. We analyzed clinical features, bedside neuro-otological examination, MRI results, and VNG findings in fixation as well as those with fixation removed. Two hundred and fourteen charts were reviewed. Twenty-six patients had vertical nystagmus with fixation removed on VNG. Only three (11.5%) of these patients had vertical nystagmus apparent with fixation (and only two had nystagmus observed clearly at the bedside with the unaided eye). Thirteen (50%) of the patients had posterior fossa lesions on MRI and eight of the rest (30.8%) were diagnosed with central vestibular disorders. Of the 13 patients with MRI-confirmed lesions, 3 patients (23.1%) had no neurological signs or conventional bedside oculomotor signs; in these cases, vertical nystagmus without fixation was the only sign of a central lesion. Our findings go against conventional teaching and show that removing fixation can uncover subtle vertical nystagmus due to central vestibular disease, particularly from focal or chronic lesions.

A Comparison of Falls and Dizziness Handicap by Vestibular Diagnosis.

There is a paucity of data that directly compares the falls rate and dizziness handicap of different vestibular diagnoses. The purpose of this study is to compare the falls rate and dizziness handicap of common vestibular diagnoses encountered among a cohort of vestibular patients at a single institution. We conducted a retrospective cross-sectional study of patients evaluated for dizziness at a tertiary care center vestibular clinic between August 1, 2017, and March 19, 2019. Vestibular diagnosis, demographic variables, comorbidities, falls status, and Dizziness Handicap Inventory (DHI) were extracted from the medical record for analysis. Associations between vestibular diagnosis and falls history or DHI were evaluated using multivariate logistic and linear regression, respectively. A total of 283 patients met our inclusion criteria with the following diagnoses: benign paroxysmal positional vertigo (BPPV; n = 55), acoustic neuroma (n = 30), Ménière's disease (n = 28), multiple vestibular diagnoses (n = 15), vestibular migraine (n = 135), or vestibular neuritis (n = 20). After adjusting for age, sex, race, medications, and comorbidities, the odds of falling was 2.47 times greater (95% CI [1.08, 6.06], p = .039) and the DHI score was 11.66 points higher (95% CI [4.99, 18.33], p < .001) in those with vestibular migraine compared to those with BPPV. Other diagnoses were comparable to BPPV with respect to odds of falling and dizziness handicap. Patients with vestibular migraine may suffer an increased risk of falls and dizziness handicap compared to patients with BPPV. Our findings highlight the need for timely evaluation and treatment of all patients with vestibular disease.

Protocol for a randomised controlled feasibility study of psychologically informed vestibular rehabilitation for people with persistent dizziness: INVEST trial

BackgroundDizziness is a common complaint that often persists and leads to disability and distress. Several cognitive and behavioural responses may contribute to the neurobiological adaptations that maintain persistent vestibular symptoms. This paper will present the protocol of a two-arm parallel group feasibility randomised controlled trial designed to determine whether a fully powered efficacy trial is achievable by examining the feasibility of recruitment, acceptability and potential benefits of an integrated cognitive behavioural therapy and vestibular rehabilitation (CBT-VR) treatment for people with persistent dizziness.MethodsForty adult patients will be recruited from a tertiary vestibular clinic with persistent movement–triggered dizziness for 3 months or longer who have moderate–high levels of dizziness handicap. Participants will be 1:1 randomised, using a minimisation procedure, to six sessions of either CBT-VR (intervention arm) or VR only (control arm). Measures will be collected at baseline and 4 months post randomisation. The primary feasibility outcomes include descriptive data on numbers meeting eligibility criteria, rates of recruitment, numbers retained post randomisation, treatment adherence and an acceptability questionnaire. Treatment effects on self-report outcomes will be estimated to determine that 95% confidence intervals for the effects are consistent with anticipated effects and minimum clinically important differences, and to provide information needed for the power calculation of an efficacy trial. A nested qualitative study will be conducted post-intervention (intervention group only) to explore the acceptability of the intervention and identify any areas in need of improvement.DiscussionIf a trial of CBT-VR is feasible, acceptability data will be used to enhance the intervention if needed and refine the multicentre RCT protocol. Future studies will need to consider the training required for other physiotherapists to deliver the intervention.Trial registrationClinicalTrials.gov, ISRCTN 10420559

Hearing Loss in Treacher-Collins Syndrome

Abstract Treacher Collins Syndrome is a craniofacial disorder that has dominant autosomal disorder in facial development, found 1 in every 50,000 births. The common manifestations can be mandibulofacial disorder, microtia, atresia of the ear canal, and hearing loss. This syndrome is also accompanied by malformations of the ossicular chain of bone in the middle ear, which can lead to conductive hearing loss up to 50% of cases and sensory neural hearing loss. The aim of this report was to present one case of Treacher-Collins Syndrome at the Audiology - Vestibular clinic Dr. Hasan Sadikin General Hospital Bandung. The main complaint of the patient is micrognathia and microtia with hearing loss in both ears. The right ear is smaller than the left ear, and supported to 2nd grade of Microtia. The patient had performed reconstruction ear surgery in the right ear, and had improvement from audiological examination after the 2nd stage of reconstruction. There was TCOF 1 gene mutation involved from this case. Conclusion: Treacher Collins syndrome is a rare inherited disorder, but the diagnose can be easily enforced. Early intervention with hearing rehabilitation, audio-verbal rehabilitation, and reconstruction ear surgery must be carried out for a better quality of life. Keyword : Treacher collins syndrome, micrognathia, microtia, hearing loss

VESTIBULAR TESTING IN CHILDREN WITH DIZZINESS AND BALANCE CONCERNS AFTER CONCUSSION: LABORATORY AND CLINICAL RESULTS

Background:Dizziness is the second most common symptom in people who sustain a concussion and there are few reports on vestibular laboratory findings in the concussed pediatric population. Studies to date have shown conflicting findings regarding incidence of peripheral vestibular disorders. Hypothesis/Purpose: The purpose of this study is to report vestibular laboratory and clinical examination findings in concussed youth referred to a multidisciplinary vestibular clinic.Methods:A retrospective chart review was performed for all patients (n=474) seen from August 2017 to March 2020 for a single comprehensive examination in a multidisciplinary pediatric vestibular specialty clinic. Data was extracted from the charts of patients (n=64) with a history of concussion referred because of chronic dizziness and/or imbalance. Each patient was examined by a neurotologist, physical therapist, and audiologist with specialized training in vestibular disorders. Vestibular laboratory testing performed by audiologists included video nystagmography (VNG) evaluation of oculomotor function and BPPV, rotational chair, video head impulse test (vHIT), vestibular evoked myogenic potentials (VEMPs), post-headshake nystagmus, and caloric irrigation. Physical therapy clinical examination included dynamic visual acuity testing (DVA), vestibular/oculomotor screening (VOMS), and sensory organization test (SOT). Not all tests were performed on every patient secondary to factors such as insurance coverage, patient tolerance, and young age.Results:1 or more components of VOMS was abnormal in 30 of 53 patients examined. DVA was completed on 40 patients, 23 of which were reported as abnormal. SOT was completed on 46 patients, 18 of which demonstrated below normal composite equilibrium scores. Laboratory findings were as follows: VEMPs (n=50) were normal in all but 1 patient, vHIT (n=59), caloric irrigation (n=26), post-headshake nystagmus (n=49), and positional testing (n=55) were normal on all patients tested. Rotational chair (n=60) was performed at 4 different frequencies and revealed low gain in 3 patients.Conclusion:Vestibular laboratory examination was normal in nearly all subjects tested. These results suggest that in concussed youth with chronic dizziness and/or imbalance, laboratory vestibular test outcomes indicative of peripheral dysfunction are rare, which contradicts previous research in this population. In contrast, clinical vestibular assessment was abnormal in more than 50% of subjects examined which suggests that clinicians should use caution interpreting clinical examination findings for diagnosing peripheral vestibular dysfunction. Abnormal clinical examination findings may be indicative of central vestibular conditions such as space and motion intolerance and PPPD in chronically dizzy pediatric patients after concussion.Tables/Figures:

The perception of family members regarding patient's vertigo and imbalance

Introduction and objectivesFamily members play a major role in the assessment and final result of the treatments of patients. The goal of the present study was to evaluate how much the perception of patients’ family members could be trusted regarding the vertigo and imbalance which they experienced. Materials and methodsA cross-sectional study was conducted on 110 patients and their family members who were referred to the Central Vestibular Clinic in Mashhad from April 2018 to September 2019. Family members were categorized as spouses, children, and other relatives of patients. Patients and their family members separately completed the Dizziness Handicap Inventory (DHI) by the paper and pencil method. DHI has a high reliability, validity, and internal consistency. ResultsMean DHI scores of patients and their family members were 45.35±20.24 and 42.01±22.83, respectively. The correlation between DHI scores of patients and family members, except children, were significant (p<.05). ConclusionA relatively weak to moderate relationship between the perception of patients and their family members, except children, was found. They were more aware of the physical aspects of vertigo and imbalance than the emotional ones.

Understanding Dizzy Patients a Cross-Sectional Analysis of Attitudes toward Diagnosis, Providers, and Treatment

To evaluate patients' attitudes regarding their dizziness, provider capabilities, and receptiveness toward treatment. Cross-sectional study. Tertiary care vestibular clinic. Ages 18 years or older, fluent in English, and who presented with a chief complaint of dizziness or vertigo. N/A. Non-validated questionnaire surveying patients' beliefs regarding the cause of their dizziness, likelihood of successful treatment, and openness to various treatment modalities. Patients were asked to complete an online non-validated survey regarding their dizziness prior to being evaluated in neurotology clinic. About 67 surveys were completed between January 2017 and September 2018. A majority of patients attributed their dizziness to their ears (n = 47, 70%), followed by the brain (n = 29, 43%). Most subjects chose "neither agree nor disagree" about whether their provider could identify the cause of their dizziness (27%). Most subjects also chose "neither agree nor disagree" that their dizziness would resolve with treatment (31%). These attitudes were not influenced by demographics, dizziness severity, anxiety, depression, or quality of life on multivariate ordinal regression modeling. Patients who experience dizziness have neutral attitudes with regards to believing that their provider will be able to identify the cause of their dizziness and whether their dizziness will resolve with treatment. These neutral attitudes are experienced by a plurality of patients and do not differ by demographic information, dizziness handicap, quality of life, depression, or anxiety.

Routine Vestibular Function Assessment in Children With Congenital CMV: Are We Ready?

Routine Vestibular Function Assessment in Children With Congenital CMV: Are We Ready?

47629 Contribution of Auditory Function to Falls Risk in Adults with Vestibulopathy

ABSTRACT IMPACT: Findings from this study will better characterize the role of hearing loss in falls risk among patients with vestibulopathy and identify groups that are most at risk for falls. OBJECTIVES/GOALS: Vestibular dysfunction and hearing loss are independent risk factors for experiencing falls. The purpose of this study is to determine the extent, if any, to which hearing loss contributes to falls in patients with concomitant vestibular dysfunction presenting to a specialty vestibular clinic. METHODS/STUDY POPULATION: A retrospective chart review of patients ≥18 years who underwent vestibular evaluation at our institution from June 1, 2015 to October 7, 2020 will be conducted. Patients who underwent vestibular evaluation also received audiologic evaluation and degree of hearing loss will be characterized by the 4-frequency pure-tone average (0.5, 1, 2, and 4 kHz) of the better hearing ear. Falls status will be determined by the response to the following question administered at clinic-check in, ‘Have you fallen in the last 90 days?’ Demographics, comorbidities, and falls-associated medications will also be collected. RESULTS/ANTICIPATED RESULTS: A total of 3,265 unique patients who underwent vestibular evaluation in the study time period were identified. Patients will be categorized into discrete groups (benign paroxysmal positional vertigo, unilateral hypofunction, bilateral hypofunction, central dysfunction, and normal) based on laboratory results. Regression models will be developed to evaluate the potential association between degree of hearing loss and falls in patients with different types of vestibular dysfunction, while adjusting for demographics, comorbidities, and falls-associated medications. DISCUSSION/SIGNIFICANCE OF FINDINGS: Findings from this study will better characterize the role of hearing loss in falls risk among patients with vestibulopathy and identify groups that are most at risk for falls. This study may potentially indicate the importance of hearing evaluation in the work-up of patients with vestibulopathy.

Subjective Cognitive Symptoms and Dizziness Handicap Inventory (DHI) Performance in Patients With Vestibular Migraine and Menière's Disease.

Cognitive symptoms in patients with vestibular disorders are far from rare, but identification of patients at risk for cognitive impairment remains poor. The Dizziness Handicap Inventory (DHI) is a widely used patient-reported outcome questionnaire for dizzy patients with several questions that address cognitive function. However, the relationship between subjective cognitive symptomatology in patients with vestibular disorders and performance on DHI is poorly characterized. Retrospective cohort study. Tertiary care vestibular clinic. Individuals with diagnoses of vestibular migraine (VM), Menière's disease (MD), and concomitant vestibular migraine and Menière's disease (VMMD) presenting to clinic between January 2007 and December 2019. Of 761 subjects, 365 had VM, 311 had MD, and 85 had VMMD. Symptoms of brain fog and chronic fatigue occurred more frequently in the VM and VMMD groups compared with the MD group (χ2 (df = 2, n = 761) = 67.8, 20.9, respectively, p < 0.0001). DHI scores were significantly higher in patients with VM and VMMD compared with those with MD (F[2,758] = 63.5, p < 0.001). A DHI score ≥ 13 suggested that the patient suffered from brain fog (sensitivity = 47.4%, specificity = 72.3%), whereas a score ≥ 15 indicated that the patient complained of chronic fatigue (sensitivity = 81.5%, specificity = 57.7%). Our results indicate a high prevalence of interictal cognitive symptoms in patients with episodic vestibular disorders. The DHI cannot be reliably used to differentiate between vestibular disorders nor detect cognitive impairment in these patient populations. Alternative methods must be used to identify vestibulopathic patients with cognitive symptoms to initiate strategies for prevention and treatment.

Normal Vestibulo Ocular Reflex (VOR) gain Measured Using the Video Head Impulse Test (vHIT) in Healthy Young Adults

Introduction: Many new objective tests to assess the function of specific structures of the vestibular organ are currently adopted in vestibular clinics. One of the objective assessments include the video head impulse test (vHIT) where gain &amp; velocity responses of eye relative to the head movements are recorded using an infrared camera. Methods: Thirty normal hearing subjects age between 18 to 25 years old participated in this study. At least ten Lateral, Left Anterior Right Posterior (LARP), and Right Anterior Left Posterior (RALP) responses were recorded for each participant by making small and rapid unpredictable head movements. Results: The average velocity gain for Lateral responses at 40 ms, 60 ms and 80 ms were 1.05 ± 0.003, 1.03 ± 0.002 and 1.01 ± 0.003 respectively. The LARP average velocity regression were 1.01 ± 0.24 for Left Anterior and 1.05 ± 0.25 for Right Posterior, with an average gain asymmetry of 5.13%. The RALP average velocity regression were 1.08 ± 0.31 for Right Anterior and 1.12 ± 0.30 for Left Posterior, with an average gain asymmetry of 5.87%. One sample T-test were conducted to compare Lateral responses to a previous study by Mossman et al. (2015) where significant differences in velocity gain at 60 ms and 80 ms between studies were found where, t (59) = 5.56, p &lt;0.01 and t (59) = 2.86, p &gt;&lt; 0.01 respectively. Conclusion: This indicates the importance of establishing on-site norms for every clinical settings as techniques used and equipment differences could affect the results.

Cross-Sectional Analysis of Cognitive Dysfunction in Patients With Vestibular Disorders.

The relationship of cognitive dysfunction and vestibular dysfunction has been established by various studies. However, the available Patient-Reported Outcome Measures questionnaires that address the main vestibular complaint fail to highlight this domain of dysfunction in this patient population. The objective of this study was to quantify and compare cognitive impairment using a validated cognitive questionnaire across several vestibular diagnoses. Cross-sectional study of 186 patients presenting to a tertiary care vestibular clinic with a diagnosis of vestibular migraine, Meniere's disease (MD), benign positional paroxysmal vertigo, or persistent postural-perceptual dizziness (PPPD). Patients completed the Cognitive Failures Questionnaire (CFQ) and the Dizziness Handicap Inventory (DHI). Mean CFQ scores for this cohort were significantly higher than similarly aged published controls (34.9/100 versus 31.3/100; p < 0.01; mean age, 45 years) as well as published controls between 65 and 74 years of age (34.9/100 versus 31.2/100; p < 0.05). Patients with PPPD or combined vestibular migraine and MD scored the highest on the CFQ and significantly higher than controls (45.1/100, p = 0.001; and 44.1/100, p = 0.006, respectively). Patients with benign positional paroxysmal vertigo had lower scores than normal controls. There is a weak but significant correlation between CFQ and DHI (r = 0.31; p < 0.001). Multivariate linear regression shows that CFQ scores were largely driven by the duration of symptoms (p < 0.001), type of diagnosis (notably PPPD; p = 0.026), and DHI (p < 0.001). Our results indicate that cognitive impairment is prevalent with chronic vestibular disorders, even in peripheral disorders such as MD. The duration of vestibular symptoms before diagnosis (and management), as well as certain etiologies, may play a bigger role in cognitive disability than age. This is not currently well-addressed in Patient-Reported Outcome Measures questionnaires and may be overlooked at the time of the diagnosis. Appropriate identification may help tailor treatment, namely rehabilitation programs, to individual patients.

Suppression Head Impulse Paradigm (SHIMP) in evaluating the vestibulo-saccadic interaction in patients with vestibular neuritis.

Evaluate the potential clinical application of the Suppression Head Impulse Paradigm (SHIMP) in evaluating the vestibulo-saccadic interaction in patients with vestibular neuritis (VN). A retrospective study was performed. Fifteen patients diagnosed with unilateral VN were identified from a database of ENT vestibular clinic from January 2011 to February 2020. Medical records were reviewed to determine clinical presentation, vestibular testing results, treatment, and recovery. Fifteen patients (7 left ear, 8 right ear, mean age 58.73 ± 10.73, six female) met the inclusion criteria and were enrolled in the study. Significant differences were found in the within-subjects analysis at T1 in DHI score (p = 0.001), VOR gain (p < 0.005), and in the percentages of impulses containing a SHIMPs saccade when the head is passively turned toward the affected side (p = 0.001). SHIMPs paradigm provides useful information about the value of vestibulo-saccadic interaction as new recovery strategies in patients with VN.

Horizontal Vestibulo-Ocular Reflex Gain Measures During Convergence Using a Monocular Video Technique.

Vestibulo-ocular reflex (VOR) response measures during convergence, which are clinically important to measure peripheral vestibular organ function during rotational and translational rapid head movements, can be implemented using existing clinically available monocular video-oculography (VOG) systems. We have developed and validated a monocular VOG technique that allows for accurate measurement of the convergence angle immediately before a rapid translational or rotational head movement. We recorded binocular eye movements while subjects performed active or passive horizontal head impulses while viewing near and far targets. We calculated the convergence angles and VOR gains using monocular and binocular methods and compared them with a geometric model. The monocular VOG technique resulted in convergence angle and VOR gain (eye velocity/head velocity) calculations that differed by ∼10% compared with values calculated using the binocular data. The monocular VOG technique can be clinically implemented using any unmodified, commercially available, monocular VOG system, provided its camera can be positioned to track either eye. Many vestibular clinics already have access to such systems. This method makes possible reliable measurement of the near-viewing horizontal angular VOR during the head impulse test, the translational VOR during the head heave test in patients, and the clinical measurement of convergence insufficiency.

Vestibular and Balance Dysfunction Following Sport-Related Concussion

Purpose Sport-related concussion is a significant public health concern that requires a multidisciplinary team to appropriately manage. Athletes often report dizziness and imbalance following concussion, and these symptoms can predict increased time to recover. Vestibular diagnostic evaluations provide important information regarding the athlete's oculomotor, gaze stability, and balance function in order to identify deficits for rehabilitation. These measures also describe objective function helpful for determining when an athlete is ready to return to play. The purpose of this clinical focus article is to provide background on the current understanding of the effects of concussion on the peripheral and central vestibular system, as well as information on a protocol that can be used for acute concussion assessment. Case studies describing 3 common postconcussion presentations will highlight the usefulness of this protocol. Conclusion Sport-related concussion is a highly visible disorder with many symptoms that may be evaluated in the vestibular clinic. A thoughtful protocol evaluating the typical presentation of these patients may help guide the multidisciplinary team in determining appropriate management and clearance for return to sport.

Clinical significance of spontaneous nystagmus in pediatric patients

ObjectiveTo analyze spontaneous nystagmus recorded in pediatric patients and determine its diagnostic value. Materials and methodsRetrospective review of 86 patients (mean age = 13.9 ± 4.7 years) with definitive spontaneous nystagmus recorded by videonystagmography (VNG). Spontaneous nystagmus was categorized and analyzed based on its characteristics. Correlations between spontaneous nystagmus and established clinical diagnoses were explored. ResultsAmong the patients seen in a period of three years at our pediatric vestibular clinic, 15.4% (86 out of 560) were found to have spontaneous nystagmus and half of them had horizontal nystagmus with a fixed-direction. The majority of cases with spontaneous nystagmus (77%, 66/86) were present without fixation only, while the presence of spontaneous nystagmus with and without fixation was found in 16 patients (19%). Most patients with spontaneous nystagmus without fixation only (68%) were diagnosed with a peripheral vestibular disorder (e.g., vestibular neuritis) or vestibular migraine. In contrast, vertical nystagmus was found in 15 patients, most of whom had central vestibular disorders. Other rare forms of nystagmus or abnormal eye movements, such as pendular nystagmus, ocular oscillation or flutter were recorded in only four patients. ConclusionsSpontaneous nystagmus in children and young adults with possible vestibular impairments may vary in clinical presentation. Identification of its characteristics may help to make an accurate clinical diagnosis. While spontaneous nystagmus associated with peripheral vestibular disorders can be readily recognized, spontaneous nystagmus in pediatric patients with vestibular migraine appears to be more complex and variable in form.

Video Head Impulse Testing in a Pediatric Population: Normative Findings.

The video head impulse test (vHIT) is a new tool being used in vestibular clinics to assess the function of all six semicircular canals (SCCs) by measuring the gain of the vestibulo-ocular reflex (VOR) in response to rapid head turns. Whereas vHIT has been validated in adults for all SCCs, there are few studies describing the normal response in children, particularly for stimulation of the vertical canals. The purpose of this study was to characterize the normal vHIT response for all six SCCs in children aged 4-12 years. A cross-sectional prospective descriptive study. Forty-one participants were categorized into one of four groups based on their age (4-6 years, 7-9 years, 10-12 years, and adults) with at least ten participants in each age group. The ICS Impulse system (GN Otometrics, Schaumburg, IL) was used to perform vHIT on each participant. Lateral, anterior, and posterior SCCs were stimulated by thrusting the head in the plane of the canal being evaluated and resulting VOR gain measures were calculated as eye velocity divided by head velocity. VOR gain of the pediatric age groups was compared with adults for all SCCs. There were no significant differences in mean VOR gain between the three pediatric age groups for any SCC measured; thus, the pediatric data were combined into one group of 30 children for comparison with the adult group. Results showed that the pediatric group had significantly higher mean VOR gain than the adult group during left lateral SCC testing. A significantly lower mean VOR gain, however, was observed for the children compared with the adult participants for left anterior and right posterior (LARP) impulses. There was a large amount of variability in the data during right anterior and left posterior (RALP) impulse testing for both the pediatric and the adult groups, which was at least partially attributed to large pupil diameter in the younger participants. Test time decreased with an increase in age for all impulse conditions (lateral, RALP, and LARP). Several modifications were necessary to obtain adequate data on the pediatric participants. vHIT can be used to successfully measure the function of the lateral SCC in children as young as 4 years of age. Our results provide normative gain values that can be used when testing children with lateral vHIT. Care must be taken to obtain the most accurate measures and reduce variability when testing children, particularly with LARP and RALP. Our data would suggest that lower gain cutoffs should be used for LARP and RALP testing in children than the cutoffs used for lateral vHIT. Further research is warranted to study LARP and RALP response reliability and validity in children because of the highly variable VOR gains found in this population. Pediatric modifications for successfully administering vHIT and obtaining reliable results are discussed.

Peripheral Vestibular Disorders in Children and Adolescents with Concussion.

Objective To review peripheral vestibular disorders in pediatric patients with dizziness following concussion. Study Design Case series with chart review. Setting Pediatric vestibular clinic and pediatric multidisciplinary concussion clinic at a tertiary level pediatric hospital. Subjects and Methods We retrospectively reviewed 109 patients seen for dizziness following a concussion between September 2012 and July 2015. Patients were ≤20 years of age at the time of concussion. Incidences of specific peripheral vestibular disorders were assessed along with timing of diagnosis relative to the date of injury, diagnostic test findings, and treatment interventions associated with those diagnoses. Results Twenty-eight patients (25.7%) were diagnosed with peripheral vestibular disorders. None of these disorders were diagnosed prior to evaluation in our pediatric vestibular clinic or our multidisciplinary concussion clinic, which occurred a mean of 133 days (95% confidence interval, 89.2-177.3) after injury. Benign paroxysmal positioning vertigo was diagnosed in 19 patients, all of whom underwent successful canalith repositioning maneuvers. Other diagnoses included temporal bone fracture (n = 3), labyrinthine concussion (n = 2), perilymphatic fistula (n = 2), and superior semicircular canal dehiscence (n = 2). Both patients with perilymphatic fistula and 1 patient with superior semicircular canal dehiscence underwent successful surgical management, while 1 patient with superior semicircular canal dehiscence was managed nonsurgically. Conclusion Peripheral vestibular disorders may occur in pediatric patients with dizziness following concussion, but these disorders may not be recognized until symptoms have persisted for several weeks. An algorithm is proposed to guide the diagnosis and management of peripheral vestibular disorders in pediatric patients with concussion.

Characteristics and Treatment Outcomes of Benign Paroxysmal Positional Vertigo in a Cohort of Veterans.

The Mountain Home Veterans Affairs (VA) Medical Center has been diagnosing and treating veterans with benign paroxysmal positional vertigo (BPPV) for almost 2 decades. The clinic protocol includes a 2-week follow-up visit to determine the treatment outcome of the canalith repositioning treatment (CRT). To date, the characteristics of BPPV and treatment efficacy have not been reported in a cohort of veterans with BPPV. To determine the prevalence and characteristics of veterans diagnosed with BPPV in a Veterans Affairs Medical Center Audiology Clinic and to examine treatment outcomes. Retrospective chart review. A total of 102 veterans who tested positive for BPPV in the Vestibular Clinic at the Mountain Home VA Medical Center from March 2010 to August 2011. In 102 veterans who were diagnosed with BPPV, the posterior semicircular canal was most often involved (75%), motion-provoked vertigo was the most common symptom (84%), and the majority (43%) were diagnosed with BPPV in their sixth decade. The prevalence of BPPV in the Audiology Vestibular Clinic was 15.6%. Forty-one percent of veterans reported a symptom onset within 12 months of treatment for BPPV; however, 36% reported their symptoms began > 36 months prior to treatment. CRT was effective (negative Dix-Hallpike/roll test) in most veterans (86%) following 1 treatment appointment (M = 1.6), but more than half reported incomplete symptom resolution (residual dizziness) at the follow-up appointment. Eighteen percent of veterans experienced a recurrence (M = 1.8 years; SD = 1.7 years). The characteristics and treatment outcomes of BPPV in our veteran cohort was similar to what has been reported in the general population. Future work should focus on improving the timeliness of evaluation and treatment of BPPV and examining the time course and management of residual dizziness.