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Vestibular Rehabilitation for Patients with Unilateral Peripheral
Vestibular Deficit
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Chang Geun Song, Sung Kwang Hong
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Res Vestib Sci. 2015;14(3):61-66.
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- Unilateral peripheral vestibular deficit can occur from a different etiology
including viral infection, trauma, ear surgery or idiopathic. Patients with sudden
unilateral vestibular deficit usually complain of whirling vertigo, postural
imbalance and ipsilesional lateropulsion, which gradually recover over a few
weeks by vestibular compensation mechanism. Vestibular rehabilitation therapy
has been accepted as helpful exercise based training program with strong evidence
for acceleration of vestibular compensation in unilateral vestibular deficit. Here
the authors described the current issue regarding vestibular rehabilitation in
unilateral vestibular hypofunction from the informative literature review.
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Multicenter Study on the Clinician’s Diagnostic and Therapeutic Approaches for Benign Paroxysmal Positional Vertigo in Korea
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Eun Ju Jeon, Won Ho Chung, Jeong Hwan Choi, Eui Cheol Nam, Hong Ju Park, Jong Dae Lee, Won Sang Lee, Kyu Sung Kim, Eui Kyung Goh, Ja Won Koo, Min Bum Kim, Min Beom Kim, Se Hyung Kim, Young Jin Kim, Chang Hee Kim, Sung Il Nam, Seog Kyun Mun, Ga Young Park, Sang Yoo Park, Shi Nae Park, Chang Hoon Bae, Sung Hyun Boo, Myung Whan Suh, Jae Hyun Seo, Eun Jin Son, Jae Jun Song, Jae Jin Song, Joong Wook Shin, Dae Bo Shim, Seong Ki Ahn, Hye Youn Youm, Shin Young Yoo, Dong Hee Lee, Seung Hwan Lee, Chang Ho Lee, Hyun Seok Lee, Hwan Ho Lee, Hyo Jeong Lee, Yun Hoon Choung, Seung Hyo Choi, Jee Sun Choi, Seok Min Hong, Sung Kwang Hong
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Res Vestib Sci. 2013;12(3):79-92.
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Abstract
- Background and Objectives: It is necessary to establish the most efficient diagnostic and therapeutic method for benign paroxysmal positional vertigo (BPPV), which is appropriate for Korean healthcare system. We aimed to evaluate current state of Korean clinician’s diagnostic and therapeutic approaches for BPPV. Materials and Methods: A 16-item survey was emailed to the members of dizziness department of Otology Research Interest Group in the Korean Otologic Society (n=68). 43 were returned and analyzed. Results: All respondents (100%) used Dix-Hallpike test as a diagnostic tool for vertical canal-BPPV. Supine roll test was used for diagnosing lateral canal BPPV in nearly all the respondents (97.7%). Epley maneuver was chosen as otolith repositioning maneuver (ORM) for posterior canal BPPV in all respondents and barbecue rotation (BBQ) was used for treating lateral canal BPPV with geotropic nystagmus in 95.3% of respondents. Extreme variation was noted for therapeutic approach of lateral canal BPPV with ageotropic nystagmus BBQ, with 4 kinds of ORM and adjunctive measures to liberate otolith from cupula, while BBQ was again the most commonly used ORM (76.7%). Conclusion: The development of practical and efficient ORM for lateral canal BPPV with ageotropic nystagmus is necessary.
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Quantitative Analysis of Fixation Index of Caloric Induced Nystagmus and Its Clinical Implication
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Joong Yeon Won, Sae Young Kwon, Ji Hee Kim, Hyo Jeong Lee, Hyung Jong Kim, Ja Won Koo, Sung Kwang Hong
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Res Vestib Sci. 2012;11(4):123-130.
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Abstract
- Background and Objectives: There is no general consensus as to the normal limit or recommended procedure for visual fixation index (VFI) during caloric test because fixation suppression (FS) could be influenced by different variables. In this study, we present our mathematical modeling according to different variables to establish a clinical implication of VFI in patients with vertigo. Materials and Methods: Data were analyzed from a retrospective record of patients who underwent caloric testing. Three subgroups were classified (normal caloric response, unilateral vestibular hypofunction and central vertigo). VFI distribution and mathematical modeling to estimate an associated probability were performed from each group. A receiver operation characteristics (ROC) curve was plotted to determine its diagnostic value. Results: Four hundred eighteen, 67 and 14 patients met our inclusion criteria for normal caloric response, unilateral vestibular hypofunction and cerebellar infarction respectively. VFIs on warm irrigation showed more consistent distribution than cold irrigation in normal caloric response group. In contrast, there was significant inconsistency of VFIs between each side in unilateral vestibular hypofunction group (p>0.05). FS ability was inversely propositional with increase in age on all caloric (p<0.05). The area under the ROC curve of VFIs on warm caloric irrigation was 0.821 and that on cold irrigation was 0.785 for detecting central vertigo. Conclusion: Calibrated normal limit for VFI according to age is needed to ensure its clinical implication. Diagnostic value of VFI and its reliability on warm stimulation was superior to that of cold, which indicates VFI on warm stimulation seems to be a more reliable parameter.
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Reliability of Air Caloric Response in Healthy Volunteers and Patients With Chronic Otitis Media
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Sung Kwang Hong, Ji Soo Kim, Jin Woong Choi, Ja Won Koo
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Res Vestib Sci. 2012;11(1):29-36.
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Abstract
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- Background and Objectives: To investigate reliability of the air caloric test compared to the water caloric test and to determine whether anatomical alterations due to chronic otitis media (COM) influence air caloric response. Materials and Methods: Fifty-six subjects without vestibulopathy (24 healthy individuals as control group and 32 patients with unilateral COM as experimental group) were included. The bithermal water and air caloric test were sequentially conducted in control group. The bithermal air caloric tests, high-resolution temporal bone computed tomography and endoscopic photography of the ear drum were obtained from experimental group. Results: Although maximal slow phase velocities and time to reach peak velocity using water irrigation were significantly higher and shorter, respectively, than those by air irrigation in normal subjects, caloric parameters on air caloric test agreed well with those of water caloric testing. However, inverted nystagmus occurred in 16 ears of 16 subjects, which was predominantly presented during warm air stimulation in the com patient group. The large tympanic membrane perforation and asymmetrical mastoid pneumatization were significant parameters affecting caloric response. The presented prediction model for cold-induced mspvs corresponded with observed values according to mastoid pneumatization. Conclusion: Although the air caloric stimuli resulted in a reliable response in healthy subjects, air caloric results among com patients affected by anatomical alteration as well as irrigation temperature. Presented mathematical model for cold induced mspv could serve as a good reference in measuring true vestibular function in com patients.
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Recording of Ictal Nystagmus in a Case of Syncope Presenting Vertigo
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Jin Woo Maeng, Sung Kwang Hong, Hyung Jong Kim, Hyo Jeong Lee
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Res Vestib Sci. 2011;10(3):103-106.
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Abstract
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- Prevalence of dizziness has been reported to be as high as nearly twenty percent and one half of these population had social handicap to some degree. The diagnostic approach of dizziness heavily relies on the premise that dizziness type predicts the underlying etiology-e.g, vertigo with vestibular causes and presyncope with cardiovascular causes. However, such symptomatological approach sometimes delays correct diagnosis as the presenting symptom of individual patient is typically vague to designate the type. In this paper, a case of a 57-year-old woman who has experienced recurrent rotatory vertigo of cardiovascular origin was discussed. When her head were turned to the left, a fast downbeat nystagmus following a slow upward eye deviation was recorded using video nystagmogram. Hence, we report this single case of syncope presented as peripheral vertigo type with literature review.
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Diagnostic Value of Cochlear Hydrops Analysis Masking Procedure in Meniere's Disease in Comparison with Electrocochleography
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Ju Sang Lee, Eun Sun Park, Sung Kwang Hong, Jung Hak Lee, Hyo Jeong Lee, Hyung Jong Kim
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Res Vestib Sci. 2011;10(1):19-25.
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Abstract
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- Background and Objectives: Patients with Meniere’s disease often present with a great variety of symptoms, especially at the onset of the disease. However, there is no single test that is definitive for making the diagnosis of Meniere’s disease. Recently, a new diagnostic test, the cochlear hydrops analysis masking procedure (CHAMP) was introduced as a test for endolymphatic hydrops. The aim of this study is to evaluate the diagnostic value of CHAMP test in Meniere’s disease in comparison with that of electrocochleography.
Materials and Methods: The CHAMP test and electrocochleography were simultaneously performed in 14 cases of definite Meniere’s disease and 8 normal healthy volunteers (16 ears). Positive criteria were defined as being more than 0.35 in summating potential/action potential (SP/AP) ratio, 0.3 ms or less in latency delay and 0.95 or less in complex amplitude ratio. Measured parameters from each test were compared between the groups, and sensitivity and specificity of each test in diagnosing Meniere’s disease were calculated.
Results: There was no significant difference in the SP/AP ratio of electrocochleography between the Meniere’s disease and control groups. In CHAMPtest, the latency delay was shorter and the complex amplitude ratio was smaller (p<0.001). While taking positive results from both test parameters, the sensitivity and specificity of CHAMP test were 85.7% and 87.5%, respectively.
Conclusion: The CHAMP seems to be a clinically useful tool in diagnosing Meniere’s disease and might be better than electrocochleography to detect endolymphatic hydrops.
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Recurrent Vertigo after Cochlear Implantation
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Kyu Hee Han, Sung Kwang Hong, Chang Myeon Song, Ja Won Koo
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Res Vestib Sci. 2009;8(1):56-59.
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Abstract
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- Post-operative dizziness and vertigo have been variously reported from 30 to 60% after cochlear implantation. There have been reported that delayed vertigo is the most common type and characterized by similarities with dizziness in Meniere’s syndrome. Authors experienced a man who had delayed onset of vertigo, which developed six months after cochlear implantation on the left side. Postoperative left caloric response was decreased in both warm and cold stimulation. The direction of spontaneous nystagmus during spell was right side with torsional down beat and definite catch up saccades were observed during head thrust test on the plane of the left horizontal canal and posterior canal, which was resolved on the next day. These episodic and recurrent spells of vertigo might suggest that the hydropic changes of labyrinth corresponding to the pathology of Meniere’s disease occurred in this patient.
Key Words: Vertigo; Cochlear implantation; Endolymphatic hydrops
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Multicenter study on the treatment pattern of Ménière’s disease in Korea
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Sung Kwang Hong, Eui Kyung Koh, Kyu Sung Kim, Kyoung Ho Park, Hong Ju Park, Seong Ki Ahn, Joong Ho Ahn, Won Sang Lee, Gi Jung Im, Jae Yun Jung, Won Ho Chung, Gyu Cheol Han, Sung Won Chae, Ja Won Koo
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J Korean Bal Soc. 2008;7(2):174-181.
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- Background and Objectives: It is hard to determine the efficacy of several treatment options of Ménière’s disease since dynamic course of the disease and diverse rate of recurrence. Few modalities are regarded as ‘effective’ in the viewpoint of evidence based medicine. Study was conducted to know the current status of treatment options for Ménière’s disease.
Materials and Methods: A multicenter survey was conducted using questionnaires to collect information on current status of treatment patterns in Ménière’s disease. The questionnaire answered by neurotologic surgeons working at 12 institutes in Korea was analyzed.
Results: Low salt diet was always instructed to their patients, but 8 out of 12 responders (67%) did not emphasis on the amount of dietary salt. Duration of pharmacotherapy was ranged from 3 to 12 months. Intratympanic steroid injection was performed in 8 institutes (67%). Every institute agreed on the role of intratympanic gentamicin application. Treatment options for intractable patients were asked. Endolymphatic sac surgery, intratympanic steroid, Meniette device and intratympanic aminoglycoside injection were answered in patients who hope to preserve residual hearing. On the contrary, in patients without serviceable hearing, intratympanic jnjection of aminoglycosides (9/12, 75%) dominated as the next treatment option.
Conclusions: Most institutes provide similar patterns of practice in medical treatment. The application of intratympanic aminoglycoside is also agreed in intractable patients without serviceable hearing. However, thoughts about the role and detailed methods of the surgical and adjunctive treatment options were not agreed, especially in intractable patients with good hearing. Further clinical studies and discussions would be necessary to provide consensus for the best treatment of Ménière’s disease in Korea.
Key words : Ménière’s disease, Pharmacotherapy, Surgery, Aminoglycosides
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Effects of Intrabullar Gentamicin Application on Guinea Pig Vestibulo-Ocular Reflex
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Ja Won Koo, Jae Jun Song, Sung Kwang Hong, Ji Soo Kim
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J Korean Bal Soc. 2008;7(1):9-16.
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- Background and Objectives: Unilateral vestibular loss can be induced by intratympanic gentamicin instillation. Despite accumulated reports on the morphologic changes after gentamicin treatment, there are limited reports regarding the effects of gentamicin ototoxicity on the vestibulo-ocular reflex (VOR), in especially unilateral vestibular deficit by local gentamicin instillation. Aim of this study is to provide the functional changes after local gentamicin application in guinea pigs.
Materials and Methods: Ten white guinea pigs (5 each for control and gentamicin treatment group) were used. Following surgical exposure of the left bulla, 0.9% saline solution or 40 mg/ml of gentamicin soaking gelfoam were applied on the round window. Horizontal vestibulo-ocular reflex (hVOR) was tested during earth vertical axis (EVA) sinusoidal harmonic acceleration rotation at 4 frequencies (0.04, 0.08, 0.16 and 0.32 Hz, 60 deg/sec of peak velocity). In one gentamicin treated animal, hVOR was tested during step velocity off-vertical axis rotation (OVAR) to clockwise and counterclockwise direction (30° forward tilt from EVA with constant velocity of 100 deg/sec). Every test was repeated before treatment and at 2 days, 5 days and 7 days after treatment.
Results: The hVOR gain was significantly lowered after gentamicin treatment at all tested frequencies (p<0.05), while the gain does not change over time in control animals. Loss of bias component was evident and some decrease of modulation component was observed in counter-clockwise (lesion side) rotation after gentamicin treatment.
Conclusion: This study provides characteristics of hVOR during EVA rotation and OVAR in unilateral vestibular deficit animal model by intrabullar gentamicin application.
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Diagnostic Value of Vestibular Evoked Myogenic Potential in Acoustic Neuroma
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Young Jin Ahn, Sung Kwang Hong, Ji Soo Kim, Ja Won Koo
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J Korean Bal Soc. 2007;6(2):138-142.
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- Background and Objectives: Considering vestibular evoked myogenic potential (VEMP) represents functional integration of the inferior vestibular nerve and large proportion of acoustic neuroma (AN) originate from inferior vestibular nerve, VEMP test may provide more valuable information than ABR and the caloric test in terms of evaluating functional integration as well as screening test. Authors hope to clarify such hypothesis and also analyzed if parameters differ between cochlear lesion and retrocochlear lesion.
Materials and Methods: Authors analyzed the results of VEMP test in 27 patients (10 males and 17 females) of AN and in 24 patients (9 males and 15 females) of unilateral definite Meniere’s disease (MD). Right-left difference of interpeak latency (IPL) and interaural amplitude difference (IAD) were used as parameters of VEMP. Longest diameter of the enhanced area was measured as the size of tumor on the axial view of Gadolium enhanced T1 weighted magnetic resonance image.
Results: VEMP was abolished in 15 out of 27 AN patients (54.5%). Among the remaining 12 patients, 1 patient showed increased IPL and IAD at same time, while 2 patients exhibited increased IAD. The mean diameter of tumor in the group who showed positive VEMP waves was significantly smaller (0.95 cm) than that of abolished VEMP group (2.22 cm)(p=0.004). Similar tendency was also present in ABR and Caloric test. However, there was not
significant difference between MD and AN in the latencies and amplitudes.
Conclusions: VEMP test may not provide diagnostic information in smaller AN, especially less than 1 cm. And parameters of VEMP were not differ between cochlear and retrocochlear lesion. However, VEMP response seems still important for the comprehensive understanding of peripheral cochleovestibular status in addition to ABR and caloric test.
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Benign Paroxysmal Positional Vertigo in Bilateral Vestibular Loss
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Jeong Hun Jang, Sung Kwang Hong, Ji Soo Kim, Ja Won Koo
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J Korean Bal Soc. 2007;6(1):53-56.
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- Usual presentations of bilateral vestibular loss are ataxia and oscillopsia. However, fluctuating dizziness is also observed in bilateral vestibulopathy patient. Fluctuating vestibular function in bilateral vestibular loss patients may suggest asymmetric progression of functional loss after compensation is partially accomplished. Because labyrinthine lesion causing vestibular loss is a predisposing factor of benign paroxysmal positional vertigo (BPPV), secondary BPPV can also be developed in bilateral vestibular loss patients. However, BPPV has been hardly noticed in bilateral vestibulopathy patients as a cause of fluctuating dizziness. Authors experienced two cases of BPPV developed in bilateral vestibular loss, one of which showed complete dead labyrinth on ice water caloric test and no significant vestibule-ocular reflex on rotation test. These cases show recurrent BPPV can be the cause of recurrent vertigo in bilateral vestibular loss patients.
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Role of Vestibular Evoked Myogenic Potentials to Elevate the Sensitivity of Objective Tests in Early Meniere’s Disease
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Ik Joon Choi, Sung Kwang Hong, Ji Soo Kim, Ja Won Koo
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J Korean Bal Soc. 2007;6(1):16-20.
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- Background and Objectives: Diagnosis of Meniere’s disease (MD) is based on detailed medical history and audiometry in addition to electrocochleography (ECoG). However, the sensitivity of ECoG is rather low and the diagnosis seems to be rather obscure if the patient is evaluated after resolution of acute symptom, especially in early stage of disease without substantial hearing loss. In such cases, if a patient complains recurrent episodes within short term period, any objective result would be beneficial to initiate medical treatment such as diuretics. Since the saccule is the main target organ in MD, authors suppose vestibular evoked myogenic potential (VEMP) test combined with ECoG may elevate the diagnostic sensitivity in MD. Aim of study is to evaluate the possibility of this suggestion.
Materials and Method: Thirty-four patients of unilateral MD who have hearing loss less than 40 dB and onset of first attack within 1 year were included in this study. They underwent VEMP, caloric test and ECoG. Abnormal rates of each test and results of combination were analyzed according to the group of MD.
Results: Patients with abnormal results in VEMP, ECoG and calorict tests were 29%, 15% and 35%, respectively. Patients showed abnormal results either in VEMP or ECoG were 41% in all MD and 72% in definite group.
Conclusions: To get higher objective evidence of cochleovestibu
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