Research in Vestibular Science

Volume 14 (4); December 2015

Reviews

Vestibular Rehabilitation in Central Dizziness: Byung In Han, Pan Woo Ko, Ho Won Lee, Hyun Ah Kim, Hyung Lee; Res Vestib Sci. 2015;14(4):97-100.

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Abstract PDF: Vestibular rehabilitation therapy (VRT) is an exercise-based treatment program designed to promote vestibular adaptive and compensatory mechanisms already existing in the human brain. Although the evidence is sparse for improvement in subjects with central vestibular dysfunction following VRT, it improves postural stability in cerebellar diseases and reduces subjective complaints and fall risk in Parkinson disease. Possible mechanisms of recovery after central nervous system lesions may include neural sprouting, vicarious functions, functional reorganization, substitution, and plasticity. VRT regimens for patients with central causes should include balance and gait training, general strengthening and flexibility exercises, utilization of somatosensory and vision and utilization of alternate motor control strategies. VRT would be an option to relieve the symptoms of the many patients who have central dizziness.

Genetic Approach of Dizziness: Jae Hwan Choi; Res Vestib Sci. 2015;14(4):101-109.

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Abstract PDF: Patients with recurrent vertigo/dizziness or unsteadiness are a heterogeneous group of complex disorders affecting the peripheral and central vestibular system. They represent a diagnostic challenge for the clinicians, and their genetic basis is largely not known. However, there are some cerebellar and vestibular disorders with a strong genetic background, such as episodic ataxia, spinocerebellar ataxia, vestibular migraine, Meniere’s disease, and autosomal dominant nonsyndromic deafness. Furthermore, recent advances in next generation sequencing technique are increasing the number of novel genes associated with cerebellar and vestibular disorders. In this article, we have summarized clinical and molecular genetics findings in neuro-otology.

Original Articles

Pathways of Neurogenic and Humoral Control in the Vestibulosympathetic Reflex of Conscious Rats: Guang Shi Jin, Gyoung Wan Lee, Sang Eon Park, Yuan Zhe Jin, Byung Rim Park; Res Vestib Sci. 2015;14(4):110-116.

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Abstract PDF: Objective: The vestibular system contributes control of blood pressure during postural changes through the vestibulosympathetic reflex. In the vestibulosympathetic reflex, afferent signals from the peripheral vestibular receptors are transmitted to the vestibular nuclei, rostral ventrolateral medullary nuclei, and then to the intermediolateral cell column of the thoracolumbar spinal cord. Physiological characteristics of the vestibulosympathetic reflex in terms of neurogenic and humoral control of blood pressure were investigated in this study.
Methods
Conscious rats with sinoaortic denervation were used for removal of baroreceptors in reflex control of blood pressure, and hypotension was induced by intravenous infusion of sodium nitroprusside (SNP). Expression of c-Fos protein was measured in the medial vestibular nuclei (MVN), rostral vestrolateral medullary nuclei (RVLM), and intermediolateral cell column (IMC) in T4-7, and levels of blood epinephrine were measured following SNP-induced hypotension.
Results
SNP-induced hypotension significantly increased expression of c-Fos protein in the MVN, RVLM, and IMC, also significantly increased level of blood epinephrine compared to normotensive control animals.
Conclusion
These results suggest that the vestibulosympathetic reflex regulates blood pressure through neurogenic control including MVN, RVLM, and IMC, also through humoral control including epinephrine secretion by the adrenal medulla following SNP-induced hypotension. The physiological characteristics of the reflex may contribute to basic treatment of impairment of blood pressure control during postural changes.

Clinical Characteristics of Horizontal Canal Benign Paroxysmal Positional Vertigo with Persistent Geotropic Direction Changing Positional Nystagmus: Kyung Min Ko, Mee Hyun Song, Jin Woo Park, Joon Hee Lee, Yong Gook Shin, Dae Bo Shim; Res Vestib Sci. 2015;14(4):117-122.

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Abstract PDF: Objective: The purpose of this study was to identify the clinical characteristics of horizontal canal benign paroxysmal positional vertigo (h-BPPV) with persistent geotropic direction changing positional nystagmus (DCPN).
Methods
One hundred thirty two patients diagnosed as the geotropic subtype of h-BPPV were analyzed retrospectively. Patients were classified into two groups: persistent h-BPPV (ph-BPPV) group which means h-BPPV showing persistent (＞1 minute) geotropic DCPN and short duration h-BPPV (sh-BPPV) group that means h-BPPV with short duration (≤1 minute) geotropic DCPN. We compared the clinical characteristics and treatment outcomes between the two groups.
Results
The study included 34 patients with ph-BPPV and 98 patients with sh-BPPV. There were no differences between the two groups in age, distribution of sex and the affected side. The ph-BPPV group had higher secondary BPPV preponderance and dizziness handicap index (DHI) score compared to the sh-BPPV group. The ph-BPPV group required higher number of canalith repositioning procedures (CRPs) until resolution and higher multiple/single CRP ratio than the sh-BPPV group. In addition, the ph-BPPV group showed longer duration until the remission of subjective symptoms (vertigo, dizziness) compared to the sh-BPPV group.
Conclusion
ph-BPPV was more frequently associated with secondary causes of BPPV and demonstrated higher DHI score, total number of CRP, and longer remission duration of subjective symptoms compared to sh-BPPV. This information may be helpful for clinicians in counseling and managing the patients with persistent geotropic DCPN h-BPPV.

Vestibular Dysfunctions in Vestibular Migraine Evaluated by Rotatory Chair Test: Ji Yun Park, Byeong Cheo Oh, Tae Kyeong Lee, Ki Bum Sung; Res Vestib Sci. 2015;14(4):123-131.

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Abstract PDF: Objective: There have been several efforts to elucidate the pathophysiology of the vestibular migraine (VM). But, there is no consistent result. This study was to identify the possible pathophysiology of VM by comparing vestibulo-ocular reflex (VOR) parameters between VM, and the tension type headache (TTH) patients. In addition, we compared VOR parameters between ictal and interictal period in the VM group.
Methods
Seventy eight patients were included: 44 having VM and 34 TTH. Three parameters (gain, asymmetry, and phase) of the horizontal VOR rotating at 60 degrees were measured. In 10 VM patients VOR parameters were obtained twice sequentially first in the ictal and second in the interictal period.
Results
Although the average of the VOR gain in VM group was lower than that of TTH group but there was no statistical significance. An asymmetry of the VOR was significantly higher in VM group. There were various changes in other VOR parameters between ictal and interictal periods with no consistent trends.
Conclusion
We could deduce that VM patients might have subclinical vestibular dysfunction from the reduced gain and increased asymmetry of the VOR in the interictal period. Dynamic changes of the VOR in the ictal period could be responsible for dizziness in VM patients, which are caused by the pathological alteration of the physiologic plasticity of the VOR.

Assessment of Vestibular Functional Recovery Using Video Head Impulse Test in Vestibular Neuritis: Jun Hyun Kim, Tae Kyeong Lee, Sang Woo Lee, Nari Choi, Seungcheol Lee, Ki Bum Sung; Res Vestib Sci. 2015;14(4):132-138.

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Abstract PDF: Objective: The video head impulse test (vHIT) is useful for evaluation of high frequency vestibulo-ocular reflex. There are a few reports regarding the recovery of head impulse test in vestibular neuritis (VN) but the factors for the recovery were not studied. The study aimed to identify the recovery patterns of vHIT in VN and the factors influencing the recovery.
Methods
Among 31 patients with acute VN, 18 patients with identified recovery pattern were selected. We conducted serial checks of subjective vertigo and spontaneous nystagmus until discharged (1?8 days), and scheduled vHITs. We found three patterns in serial vHITs during follow-ups and analyzed the relationship of initial vestibular function tests, serial check-ups of subjective vertigo, bedside neuro-otologic tests, and vHITs.
Results
Five patients showed normal vHIT gain in acute stage (non-damaged pattern) and 8 patients’ gains were recovered after 30 days after symptom onset (early recovered pattern). Poor recovery pattern was found in 5 patients (poorly recovered pattern). There were relationship between vHIT recovery patterns and the severity of vestibular dysfunctions. Duration of spontaneous nystagmus (until grade 1), degree of subjective visual vertical tilt, ocular vestibular myogenic potential abnormalities, and abnormality of rotatory chair test were all related to poorly recovered vHIT patterns. All poor recovery patients had residual symptom at 30 days after symptom onset.
Conclusion
The vHIT may give clinicians useful hints in predicting prognosis in VN, and the recovery of vHIT would be delayed if the damage were more extensive.

Case Reports

A Case of a Meningeal Carcinomatosis of the Internal Auditory Meatus Treated as Sudden Deafness: Fumiyuki Goto, Miki Arai, Takeshi Wakabayashi, Tomoko Otomo, Ryoto Nagai, Shuujiro Minami, Takanobu Shimada, Masato Fujii; Res Vestib Sci. 2015;14(4):139-142.

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Abstract PDF: We describe a case of meningeal carcinomatosis of the internal auditory meatus presenting as sudden deafness accompanied by dizziness. A 54-year-old woman complained of acute right-side hearing loss in October 2014. The pure tone audiometry test revealed right-side hearing loss of 47.5 dB. She was treated with oral steroids. Her hearing as well as her symptoms of dizziness worsened and she was admitted for further examination. Her right and left-side hearing had worsened to 105.0 dB and 47.5 dB, respectively. A magnetic resonance imaging scan of the head revealed bilateral enhancement of the internal auditory canal and multiple brain metastases. The chest radiograph revealed a mass in the left lung. Adenocarcinoma of the lung was diagnosed. Lumbar puncture yielded no evidence of carcinoma cells in the cerebrospinal fluid, but an increased number of lymphocytes was confirmed. A diagnosis of multiple brain metastases and leptomeningeal metastasis from the adenocarcinoma of the lung was considered. Whole-brain radiation therapy (30 Gr/10 fractions) was administered. Progressive bilateral hearing loss is a rare first manifestation of meningeal carcinomatosis. It is quite important to consider the possibility of this condition when patients present with sudden deafness.

A Case of Cerebellar Metastasis Mimicking Vestibular Neuritis: Yeong Joon Kim, Chang Hoi Kim, Hwan Ho Lee; Res Vestib Sci. 2015;14(4):143-146.

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Abstract PDF: Vestibular neuritis is characterized by rapid onset of vertigo, nausea and vomiting without neurological symptoms or signs, but central vestibular lesions can cause similar symptoms and signs. A 66-year-old woman previously diagnosed with ovarian cancer initially presented with vertigo. The patient had typical symptoms and signs of vestibular neuritis. As time proceeded, the patient presented with bilateral catch-up saccade and the symptoms and signs of cerebellar dysfunction. Magnetic resonance image and computed tomography scan showed brain metastasis surrounded by edematous lesion. We report an ovarian cancer patient with metastasis mimicking vestibular neuritis with a review of related literature.

Delayed Positional Vertigo after Stapes Surgery: Jin Woo Park, Joon Hee Lee, Mee Hyun Song, Dae Bo Shim; Res Vestib Sci. 2015;14(4):147-151.

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Abstract PDF: Postoperative vertigo can occur after stapes surgery in approximately 5% of the patients, which more commonly presents immediately after surgery rather than in the delayed period. Isolated delayed vertigo after stapes surgery is commonly related to perilymphatic fistula. Herein we report a 36-year-old female patient who developed positional vertigo 18 days after stapes surgery demonstrating severe geotropic horizontal positional nystagmus on both sides during supine roll test. This patient was eventually diagnosed as the horizontal semicircular canal benign paroxysmal positional vertigo (BPPV) on the left side. This is a rare case of delayed vertigo following stapes surgery caused by BPPV rather than perilymphatic fistula.

Preserved Ocular Vestibular Evoked Myogenic Potential to Head Tap in a Patient with Positive Head-Heave: Seong Hae Jeong, Carol A Foster, Darcy Strong; Res Vestib Sci. 2015;14(4):152-154.

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Abstract PDF: Vestibular function can be evaluated using various clinical and laboratory findings. Among these, head heave and vestibular evoked myogenic potential (VEMP) represent the otolith-ocular response, which is dynamic rather than static. There have been no reports of tap-evoked VEMP and head-heave in dizzy patients. Here, we report dissociation between ocular VEMP to head tap and the head heave test in acute vestibulopathy.

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