Research in Vestibular Science

Volume 2 (2); December 2003

Original Articles

Effect of Ginkgo biloba on Expression of c-Fos Protein in the Vestibular Nuclear Complex following Unilateral Labyrinthectomy in Rats: Dong Ok Choi, Sun Kyung Kim, Myung Ae Choi, Moon Young Lee, Min Sun Kim, Eun Ho Park, Byung Rim Park; J Korean Bal Soc. 2003;2(2):163-169.

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Abstract PDF: Background
and Objectives: The neuroprotective effect of Ginkgo biloba has been demonstrated in several in vivo and in vitro models. The effect of Ginkgo biloba on vestibular compensation following unilateral labyrinthectomy (UL) was investigated. Material and Methods: Spontaneous nystagmus and c-Fos protein expression were measured following UL in Sprague-Dawley rats with pretreatment of Ginkgo biloba (50 mg/kg, i.p.).
Results
After pretreatment with Ginkgo biloba (50 mg/kg, i.p.) expression of c-Fos protein in the vestibular nuclear complex and frequency of spontaneous nystagmus were measured till 24 hours after UL. UL produced spontaneous nystagmus with frequency of 124±2.2 beats/min at post-op 2 hrs and 70±3.1 beats/min at post-op 24 hrs. Pretreatment with Ginkgo biloba significantly decreased the frequency of spontaneous nystagmus till post-op 24 hrs compared to control group (p<0.05). UL produced marked expression of c-Fos protein in bilateral medial vestibular nucleus, inferior vestibular nucleus, and superior vestibular nucleus, and the number of expression was significantly higher in contralateral vestibular nuclei to the lesion than ipsilateral vestibular nuclei at post-op 2 hrs (p<0.01). The number of c-Fos protein expression was decreased with time and significantly higher in ipsilateral vestibular nuclei than contralateral ones at post-op 24 hrs (p<0.01). Pretreatment with Ginkgo biloba significantly decreased the number of c-Fos protein expression following UL (p<0.01) and abolished the asymmetry of c-Fos protein expression in bilateral vestibular nuclei at post-op 24 hrs.
Conclusion
These results suggest that Ginkgo biloba may facilitate vestibular compensation following UL through modulation of neurotransmitters and neuroprotective effects.

Immunohistochemical Identification of Phosphorylated Extracellular Signal-Regulated Kinase1/2 in Rat Vestibular Nuclei by Unilateral Labyrinthectomy: Myoung Ae Choi, Dong Ok Choi, Kwang Yong Kim, Moon Young Lee, Byung Rim Park, Min Sun Kim; J Korean Bal Soc. 2003;2(2):170-174.

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Abstract PDF: This study evaluated the expression of phosphorylated signal-regulated kinase1/2 (pERK1/2), which is one of the main factors regulating transcription of the cfos oncogene in neurons, in the vestibular nuclei of Sprague-Dawley rats following unilateral labyrinthectomy (UL). Surgical UL was performed to eliminate afferent signals from the peripheral vestibular receptors in the inner ear, under a surgical microscope, 2 hours after anesthesia. Significant numbers of pERK1/2 immunoreactive neurons were seen in the superior, medial, and inferior vestibular nuclei. There were more pERK1/2 immunoreactive cells in the vestibular nuclei contralateral than in the vestibular nuclei ipsilateral to the injured labyrinth, which resulted in significant asymmetric expression of pERK1/2 immunoreactive cells. Subsequently, the pERK1/2 immunoreactivity decreased rapidly, disappearing 90 min after labyrinthectomy. No pERK1/2 labeling was seen in the lateral vestibular nucleus. These results suggest that intracellular signal pathways for the activation of extracellular signal-regulated kinase in the vestibular nuclei are involved in lesion-neural plasticity in the vestibular system.

Head Position Dependency of Induced Nystagmus to Ice Water Irrigation in peripheral vestibulopathy: Byung Yoon Choi, Ja Won Koo, Seung Ha Oh, Sun O Chang, Chong Sun Kim; J Korean Bal Soc. 2003;2(2):175-180.

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Abstract PDF: Background
s and Objectives: The direction of caloric nystagmus depends on the head position as long as vestibular function is remaining but the it does not depend on head position change in the lateral semicircular canal (SCC) plugged ear, which is attributed to thermoconvection in the lateral SCC. So determination of head position dependency using ice water test is recommended in the evaluation of peripheral vestibulopathy in which dead labyrinth is suspected. Since ice water test in prone position is frequently skipped and neglected in many vestibular laboratories, we investigated the importance and necessity of evaluating head position dependency for the candidates of ice water test and estimated the amount of head position non-dependent component in discussion. Materials and method: From January through September 2003, 25 patients, who showed no nystagmus during warm irrigation, were included in this study. Following forty milliliter of ice water irrigation in supine & prone position, the maximum slow phase eye velocity (SPEV) and direction of nystagmus were assessed using video nystagmography system.
Result
Eleven cases showed head-position dependency and were interpreted as hypofunction of lateral SCC. Fourteen cases did not show head position dependency suggesting the absence of end organ function. However, in the latter group, 6 patients, who showed definite nystagmus to ice water irrigation in supine position, can be midinterpreted as hypofunction if ice water test in prone position is not performed.
Conclusion
Evaluation of head position dependency in ice water irrigation is an important procedure in the determination of lateral SCC function and can provide valuable information when vestibular ablative procedures are considered.

The Clinical Significance of Head-shaking Nystagmus in the Patients with Acute Unilateral Peripheral Vestibular Loss: Jun Sun Shin, Bo Young Kim, Kyu Sung Kim, Seung Chul Lee; J Korean Bal Soc. 2003;2(2):181-186.

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Abstract PDF: Background
and Objectives: In unilateral peripheral vestibular loss patients, head-shaking induce a bias from remaining asymmetric vestibular sensor and cause the imbalance in velocity-storage mechanisms. Head-shaking nystagmus(HSN) is the transient nystagmus induced by shaking the head in the horizontal plane, and have slow phases directed toward the side of vestibular loss. We evaluated the usefulness of the HSN in acute unilateral peripheral vestibular loss patient with reference to spontaneous nystagmus SN), bithermal caloric test, and slow harmonic acceleration(SHA) test. Materials and Methods: 18 patients of acute unilateral peripheral vestibular loss who had SN and symptoms of acute prolonged vertigo were analyzed retrospectively. The examiner performed passive head rotation in 30 degree anteflexed position with eyes closed and oscillated about 60 degree to each side, 2 Hz for 20 cycles, and the nystagmus was observed with Frenzel glasses immediately after head was stopped. Prevalence and direction of HSN were analyzed with SN, caloric test and SHA test during the follow up period.
Results
The prevalence of HSN was 89%(16/18). During follow-up period, direction of nystagmus was changed 28%(13/18) in SN, but in HSN, direction was fixed in all subjects. SN and HSN directed toward the same side in 75%(12/16) but in four cases(25%), direction could not compared because the direction of SN was changed during follow up peroid. In 69%(11/16) of subjects, HSN persisted after the disappearance of SN. In comparison of HSN with bithermal caloric test, direction of CP was highly correlated with direction of HSN(92%) than SN(64%). HSN was more prevalent(92%) than DP(67%) in caloric test and asymmetry(78%) in SHA test.
Conclusions
HSN test, easily performed office maneuvers, is very useful method to identify the laterality of acute unilateral peripheral vestibular loss, especially in chronic stage.

Reliability of history taking in the diagnosis of benign paroxysmal positional vertigo: Byung Kun Kim, Hee Joon Bae, Ja Seong Koo, Oh Hyun Kwon; J Korean Bal Soc. 2003;2(2):187-190.

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Abstract PDF: Background
and Objectives: Patients with benign paroxysmal positional vertigo (BPPV) usually have typical history. They usually complain of vertigo that lasting a few seconds to a minute. It usually occurs in the morning after awaking and provoked by typical positional change such as head turning, sitting, and lying down. However, some patients may describe their vertigo in a rather atypical way, so there is no absolute reliability of a diagnosis based on history taking. To evaluate the reliability of a diagnosis based on history taking, we performed prospective studies. Materials and Methods: We obtained structured history from all the patients with BPPV. Total of 408 patients were diagnosed as having BPPV. The diagnosis was based on typical findings of vertigo and nystagmus by Dix-Hallpike maneuver and head turning in supine position.
Results
Duration of vertigo was more than 10 minutes in 22% of patients. Position-precipitating factors were not spontaneously reported by 37%. 16% of patients complained non-spinning vertigo. 38% of patients could not tell the side to which the spell occurs. In 83 cases (20%), it was impossible to diagnose BPPV based upon a typical history.
Conclusion
We conclude that non-paroxysmal, non-positional vertigo dose not rule out BPPV. The provocation test is mandatory in those complaining of dizziness regardless of history since BPPV can be quickly diagnosed by provocation test and easily treated.

The Comparison of Benign Paroxysmal Vertigo of Childhood and Migraine Related Vertigo in Children: Yun Hoon Choung, Min Jung Cho, Ho Seok Choi, Seung Joo Lee, Jinseok Lee, Jeong Min Jeon, Sung Su Baik; J Korean Bal Soc. 2003;2(2):191-197.

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Abstract PDF: Background
and Objectives: Benign paroxysmal vertigo of childhood (BPVC) and migraine related vertigo (MRV) are most common causes of vertigo in children. Some authors suggested that BPVC may be an early manifestation of migraine. However there is few articles about relationship between BPVC and MRV. The purpose of this study is to compare the clinical characteristics, audiological and vestibular findings, treatment and prognosis of BPVC and MRV and to provide the helpful information for relationship between BPVC and MRV. Materials and Method: The twenty four children (less than 16 years old) with BPVC and 23 children with MRV, who visited the Dizziness Clinic in the Department of Otolaryngology, Ajou University Hospital, Suwon, Korea between January 2001 and August 2003 were selected for this study. These excluded the patients with abnormal eardrums/tympanograms or those that did not perform questionnaires, audiological, or vestibular evaluations. They were retrospectively analyzed for clinical symptoms, audiograms, vestibular functions, and treatment results.
Results
BPVC was frequently detected in younger children than MRV. Spinning sensation was frequently associated with BPVC. Aural symptoms, headache, photophobia, phonophobia, and visual symptoms were frequently associated with MRV. Abnormalities in vestibular function tests were 14 (58%) in BPVC and 15 (62%) in MRV. BPVC & MRV had good prognosis. But medication was sometimes more needed in MRV than in BPVC.
Conclusions
BPVC and MRV show some different features in the age of onset, clinical features, treatment and prognosis, but also have some features of MRV. Further studies are needed to find their relationship between them.

Analysis of Vertigo in Labyrinthine Fistula Secondary to Cholesteatoma: Gyu Cheol Han, Joo Hyun Woo; J Korean Bal Soc. 2003;2(2):198-201.

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Abstract PDF: Background
and Objectives: Labyrinthine fistula is one of the common complication of the chronic otitis media with cholesteatoma. Disruption of the labyrinthine bone can lead to hearing loss and/or vestibular disturbance. This study aimed to evaluate postoperative vertigo result in patient with labyrinthine fistula and efficacy of vestibular function test for diagnosis. Materials and Method: A retrospective study of the clinical records of 13 patients who were operated for chronic otitis media with cholesteatoma, suspected to have secondary labyrinthine fistula, from January 2001 through June 2003 in Gachon medical school Gil hospital. All patients were evaluated by Fistular test, Vestibular function test, high resolution Temporal bone CT, Pure tone audiometry preoperatively. Vertigo was assessed by Disability Scale.
Results
Canal wall down mastoidectomy were applied in all ears. Labyrinthine fistulas were confirmed in 8 patients during operation. Fistular group had higher rate of peripheral vestibular injury than no-fistular group's in vestibulo-ocular reflex. Fistula cases have high average score (2.9) than non-fistula's (1.6) in Vertigo scale preoperatively. In post-operation, the average score was 0.25 in fistular cases and 0.4 in non-fistula cases. 2 cases presented positive fistular test result (25.0%)
Conclusion
Although Vertigo was more severe in patients who had fistula, in post-operation, symptoms could be relieved a lot. Vestibular function test had efficacy for diagnosis of labyrinthine fistula in preoperative.

Evaluation of Vestibular Function in Ramsay Hunt Syndrome: Gyu Cheol Han, Jung Kook Yoo, Kyu Sung Kim; J Korean Bal Soc. 2003;2(2):202-205.

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Abstract PDF: Background
and Objectives: Ramsay Hunt syndrome is herpes zoster of the facial nerve, frequently associated with VIII cranial nerve involvement, but on rare occasions other cranial nerves are affected as well. We tried to show that Ramsay Hunt symdrome should be recognized as a cranial polyneuropathy characterized by damage to cranial nerves, especially the facial nerve and the auditory-vestibular nerve. Materials and Method: 11patients suffered from auricular vesicles, otalgia, facial palsy, and vertigo. Group A included 8 patients of acute peripheral vestibulopathy with Ramsay Hunt syndrome. Group B included only 3patients of Ramsay Hunt syndrome. Each patient received a battery of tests, including neurological examination, audiometry, vestibular function test.
Results
The lesion site of Ramsay HHhhunt syndrome was right in 5cases and left in 6cases. Electronystagmography showed 3cases of right acute peripheral vestibulopathy, 5cases of left, and 3cases of disequilibrium. Site of Ramsay hunt syndrome and that of vestibulopathy was same in 8cases of Group A. 3cases was observed in Ramsay Hunt syndrome patients that hearing loss and vestibulopathy was same site. Facail nerve palsy improved without recovery of vestibular function. Cranial examination and imaging study like brain CT or temporal MRI showed no abnormal finding.
Conclusion
Although Ramsay Hunt syndrome usually presents with the classical triad of pain, vesicles and facial nerve paralysis, it must be kept in mind that it is a cranial polyneuropathy. In our study, there was few association between facial nerve palsy recovery and acute peripheral vestibulopathy.

Clinical Analysis of the Dizzy Patients in a Department of Emergency Medicine: Gyu Cheol Han, Eun Jung Lee, Jong Su Ha, Dong Kyu Kim; J Korean Bal Soc. 2003;2(2):206-210.

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Abstract PDF: Background
and Objectives: The patient presenting to the emergency department with the complaint of dizziness is one of the most common as well as most challenging problems confronting the emergency physician today. Dizziness is a vague symptom of disease ranging from serious to benign. The differential diagnosis and proper management of dizziness in a department of emergency medicine are the most important things. We undertook this study to evaluate the character and clinical analysis of the dizzy patients and to discuss the significance and necessity of primary care in a department of emergency medicine. Materials and Method: From September 1999 to October 2003, we sampled the 1,371 dizzy patients who visited the Emergency Department(ED). Of these patients, the 650 patients performed electronystagmography(ENG) and rotatory chair test were selected, except for the patients with loss of consciousness, known psychiatric disease or direct brain injury.
Results
The 650 patients were attributed to acute peripheral vestibulopathy in 88.5% (575 patients) of patients, benign paroxysmal positional vertigo in 9.5% (62 patients) of patients, central origin in 1.4% (9 patients) of patients, other organic origin in 0.6% (4 patients) of patients. In a retrospective analysis of patients with central origin, the symptoms estimated at central origin, for example, persistent headache, were found.
Conclusion
The exact diagnosis and management for the dizzy patients in a department of emergency medicine require the primary physician's concern and understanding for dizziness.

The study of galvanic vestibular stimulation in patients of total unilateral vestibular loss: Hyun Jik Kim, Chang Woo Kim, Won Sang Lee; J Korean Bal Soc. 2003;2(2):211-217.

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Abstract PDF: Objectives
The aim of this study was to observe the nystagmus of totally unilateral vestibular function loss on galvanic vestibular stimulation and the diagnostic value of galvanic vestibular stimulation. Additionally we wanted to evaluate which portions may be stimulated by galvanic vestibular stimulation. Materials and Methods: We evaluated the three parameters of galvanic stimulation in fourteen patients with totally unilateral vestibular function loss, 1)spontaneous nystagmus, 2)galvanic stimulating nystagmus, 3)Post galvanic stimulating nystagmus through 3-dimensional video-oculography technique.
Results
When negative electrode was attached to the intact side, The nystagmus on galvanic vestibular stimulation was directed to the negative electrode side in all patients and post galvanic stimulating nystagmus was directed to the opposite side but on functional loss side, we couldn't detect any nystagmus on galvanic vestibular stimulation and in 10 patients, post galvanic stimulating nystagmus was observed and directed to the intact side.
Conclusions
Galvanic vestibular stimulation is very useful for evaluating the vestibular function and for diagnosing the vestibular disease.

Case Reports

A Case of Intralabyrinthine Schwannoma that Mimicked Meniere's Disease: Kyu Sung Kim, Geun Wook Jang, Tae Yong Yang, Tae Youn Kim; J Korean Bal Soc. 2003;2(2):221-226.

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Abstract PDF: Intralabyrinthine schwannomas are rare benign tumors that arise from the terminal ends of the eighth cranial nerve. These may involve the cochlea, vestibule, or semicircular canals. These tumors are uncommon, and were diagnosed incidentally either during labyrinthectomy or at autopsy. The increasing use of the MRI in the diagnostic assessment of patients with unilateral sensorineural hearing loss or tinnitus has led to the diagnosis of intralabyrinthine schwannomas. Because the clinical symptoms of intralabyrinthine schwannomas and other otologic disorders, particularly Meniere's disease, are so similar, diagnosis of intralabyrinthine schwannomas is challenging. We report a patient with intralabyrinthine schwannoma, who had been misdiagnosed as having Meniere's disease. With the aid of MRI, intralabyrinthine schwannoma was detected and removed successfully by translabyrinthine approach.

Ocular Contrapulsion in Medial Medullary Infarction: Ji Soo Kim, So Young Moon, Seon Mi Jeong, Moon Ku Han, Seong Ho Park; J Korean Bal Soc. 2003;2(2):227-230.

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Abstract PDF: Ocular contrapulsion refers to a syndrome of static ocular deviation and saccadic hypermetria toward the intact side, and saccadic hypometria and impaired smooth pursuit toward the lesion side. It has been reported in patients with lesions in the rostral cerebellum and caudal medullary hemorrhge. We report a 60-year-old man who showed ocular contrapulsion with unilateral upper medial medullary infarction. Ocular contrapulsion may be a sign of medial medullary infarction. In our patient, the climbing fibers may be damaged before crossing the midline in the upper medulla.

A case of Tolosa-Hunt syndrome with isolated superior division palsy of the oculomotor nerve: Ki Bum Sung, Tae Kyeong Lee, Sun Ah Park, Moo Young Ahn; J Korean Bal Soc. 2003;2(2):231-233.

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Abstract PDF: .

A Case of Vogt-Koyanagi-Harada syndrome presenting initially with recurrent vertigo: Tae Kyeong Lee, Sang Won Nam, Sun Ah Park, Ki Bum Sung; J Korean Bal Soc. 2003;2(2):234-236.

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Abstract PDF: Besides meningism, dizziness has also been frequently reported as a neurologic manifestation of Vogt-Koyanagi-Harada(VKH) syndrome. These neurotologic symptoms usually develop just before or after ocular involvement. We report the patient with VKH syndrome who showed recurrent peripheral vertigo. The characteristic opthalmological symptoms developed later in this case.

Isolated nodular infarction and vestibular neuritis: Hyung Lee, Yong Won Cho; J Korean Bal Soc. 2003;2(2):237-240.

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Abstract PDF: An isolated nodular infarction presenting as an isolated vertigo with unidirectional, gaze-fixed nystagmus has not been previously reported. We reported a patient with cerebellar infarction who presented with purely isolated vertigo, ipsilesional, spontaneous nystagmus, and contralesional axial lateropulsion without usual symptoms or signs of cerebellar dysfunction. An MRI of the brain showed a small infarct selectively involving the nodulus. A pure vestibular syndrome in our patient may be explained by an ipsilateral involvement of nodulo-vestibular inhibitory projection to vestibular nucleus. Clinicians should be aware of the possibility of a nodulus infarction in patients with an acute vestibular syndrome, even if the pattern of nystagmus and lateropulsion is typical of vestibular neuritis.

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