Research in Vestibular Science

Case Report

A case of vertebrobasilar dolichoectasia manifesting as sudden sensorineural hearing loss with vertigo: Young Jae Lee, Wonyong Baek, Gi-Sung Nam; Res Vestib Sci. 2024;23(1):32-36. Published online March 15, 2024; DOI: https://doi.org/10.21790/rvs.2024.004

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Abstract PDF: Vertebrobasilar dolichoectasia (VBD) is a rare vascular condition characterized by the elongation, widening, and tortuosity of the vertebrobasilar artery. It can lead to various symptoms due to compression of cranial nerves and brainstem structures. We report a rare case of VBD presenting as sudden sensorineural hearing loss (SSNHL) with vertigo and spontaneous downbeat nystagmus in a 65-year-old woman with a history of hypertension. Magnetic resonance imaging revealed a tortuous and dilated right vertebrobasilar artery compressing the brainstem and left 8th cranial nerve root entry zone, without signs of acute cerebellar stroke. The compression of the anterior inferior cerebellar artery and cervicomedullary junction was also noted, suggesting a vascular cause for her symptoms. Following high-dose steroid treatment, the patient showed significant hearing improvement. This case underscores the importance of considering VBD in patients with unexplained SSNHL and vertigo, highlighting the role of detailed vascular imaging in the diagnosis and management of such cases.

Original Article

The clinical significance of arterial stiffness in the differential diagnosis of vertigo: Bang-Hoon Cho, Jae-Myung Kim, Young-In Kim, Seung-Han Lee; Res Vestib Sci. 2024;23(1):16-23. Published online March 15, 2024; DOI: https://doi.org/10.21790/rvs.2024.003

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Abstract PDF Supplementary Material: Objectives
Pulse wave velocity (PWV) is a known indicator of arterial stiffness reflecting vascular damage. However, there are few reports of the relationship between PWV and dizziness/vertigo of a vascular origin. We investigated whether the PWV value could be useful as an ancillary measurement for identifying the etiology of dizziness/vertigo.
Methods
We enrolled dizzy patients from March 2016 to December 2018. The patients with posterior circulation stroke presenting with dizziness/vertigo were categorized as having central vertigo. The patients with vertigo due to benign paroxysmal positional vertigo, Ménière disease, or acute unilateral vestibulopathy were categorized as having peripheral vertigo. The PWV value, ankle-brachial index (ABI), and traditional vascular risk factors were collected.
Results
We consecutively enrolled a total of 93 participants. The PWV values were higher in the central vertigo group (p<0.001), but ABI did not differ between the groups. Among the vascular risk factors, the number of patients with diabetes mellitus, dyslipidemia, and male patients was significantly higher in the central vertigo group. The brachial-ankle PWV (baPWV) values were higher in the central vertigo group, even after adjusting for confounding factors (p<0.01). The receiver operating characteristic curve showed that the sensitivity was 74% and specificity was 81% when the mean baPWV value was 14.78 m/sec.
Conclusions
Increased baPWV values were observed in patients with dizziness/vertigo due to stroke. Measurement of the baPWV value could be an ancillary test for evaluating the cause of dizziness/vertigo, even though more convincing evidence is still required.

Case Report

A case of cerebellopontine angle meningioma presenting as neurovascular compression syndrome of the 8th cranial nerve: Jeongin Jang, Sung Kwang Hong, Joonho Song, Hyung-Jong Kim, Hyo-Jeong Lee; Res Vestib Sci. 2024;23(1):28-31. Published online March 15, 2024; DOI: https://doi.org/10.21790/rvs.2023.141

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Abstract PDF: A 54-year-old female patient presented with paroxysmal tinnitus and vertigo for 2 years, which have repeatedly occurred while rotating her neck, and lasted about 10 seconds. An anticonvulsant medication was prescribed with a diagnosis of microvascular compression syndrome on the 8th cranial nerve and audiovestibular evaluation and magnetic resonance imaging (MRI) scan were appointed a week later. In her next visit, she reported the disappearance of paroxysmal audiovestibular symptoms after medication. In the left ear, canal paresis and abnormal auditory brainstem response were observed. In MRI, a large meningioma in the cerebellopontine angle in the vicinity of the internal auditory canal orifice was detected, that was surgically resected by a neurosurgeon. After surgical removal of the tumor, she reported continuous dizziness due to vestibular nerve injury, but the paroxysmal attack of tinnitus and vertigo disappeared without anticonvulsant medication. This case suggests that an imaging study is mandatory when diagnosing microvascular compression syndrome on the 8th cranial nerve.

Original Article

Clinical Outcomes of Endolymphatic Sac Decompression Surgery in Menière’s Disease: Hee Won Seo, Young Sang Cho, Won-Ho Chung; Res Vestib Sci. 2023;22(4):97-105. Published online December 15, 2023; DOI: https://doi.org/10.21790/rvs.2023.22.4.97

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Abstract PDF: Objectives
Endolymphatic sac decompression surgery (ESDS) is one of the surgical methods for intractable Menière’s disease (MD), and it is known as a relatively safe treatment that does not cause hearing loss. However, the effectiveness and the degree of vertigo control rate of ESDS are still controversial. In this study, we aimed to evaluate the clinical outcomes of ESDS in intractable MD.
Methods
We retrospectively reviewed 33 patients who underwent ESDS for intractable MD from January 2002 to March 2022. Clinical characteristics of patients, pure tone threshold, medical treatment method, and number of vertigo attacks before and after surgery were assessed. The improvement of hearing and vertigo was evaluated according to the 1995 American Academy of Otolaryngology-Head and Neck Surgery criteria.
Results
Of the 33 patients, the average follow-up period was 21.2 months, with immediate follow-up within 2 months (28 patients), short term between 2 and 6 months (27 patients), and long term at 12 months or later (29 patients). In the immediate hearing threshold, both air conduction and bone conduction showed slight deterioration, but there was no significant change in the long-term hearing threshold. At long-term follow-up, 12 patients (41.4%) were able to live without medication, and 18 patients (62.1%) showed improvement in their vertigo symptoms. In addition, patients who showed improvement in hearing also showed improvement in vertigo at the same time.
Conclusions
ESDS in intractable MD is a relatively safe and effective treatment method for reducing vertigo attack without worsening hearing threshold.

Case Reports

Dural Arteriovenous Fistula Presenting as Acute Unilateral Vestibulopathy: Won Jeong Son, Jieun Roh, Eun Hye Oh, Jae-Hwan Choi; Res Vestib Sci. 2023;22(4):127-131. Published online December 15, 2023; DOI: https://doi.org/10.21790/rvs.2023.22.4.127

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Abstract PDF: Intracranial dural arteriovenous fistula (dAVF) is characterized by an abnormal connection between branches of arteries and veins in the dura mater. Clinical manifestations of dAVF vary depending on their location, feeder arterial supply, amount of shunting, and most importantly, their venous drainage pattern. Acute vertigo has been rarely reported as an initial presentation of dAVF due to venous congestion in the brainstem. We report a patient who presented with acute right vestibulopathy without any brainstem signs in dAVF involving the transversesigmoid sinus. The patient showed abnormal caloric response but normal head impulse in the affected ear. Without any treatment, the patient’s symptoms gradually improved with a normalization of right canal paresis. Follow-up cerebral angiography also revealed a spontaneous regression of the shunt flow and reduction of venous drainage at the right transverse-sigmoid sinus. Based on the results of vestibular function tests and cerebral angiography, acute vertigo in our patient may be ascribed to impaired reabsorption of endolymph by focal venous congestion.

A Rare Case of Isolated Infarcts of the Pons with Sudden Vertigo: Clinical Features and Imaging Findings: Dong Hwan Kwon, Eun kyung Jeon, Young Joon Seo; Res Vestib Sci. 2023;22(3):89-94. Published online September 15, 2023; DOI: https://doi.org/10.21790/rvs.2023.22.3.89

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Abstract PDF: Isolated infarcts of the pons (IIP) are a rare subtype of ischemic stroke, accounting for less than 1% of all strokes. It refers to a specific type of ischemic stroke that occurs within the pons region of the brain. IIP can be associated with vertebrobasilar insufficiency in certain cases. This case report describes a 64-year-old female patient who presented with acute vertigo and spontaneous nystagmus to the lesion side, ultimately diagnosed with IIP in the posterior right side of pons. Tegmental pontine infarcts typically manifest as oblique small (lacunar) infarctions that are localized in the mediolateral tegmental area of the middle to upper pons. The patient’s symptoms resolved spontaneously, but a 2-mm infarct was confirmed by brain diffusion magnetic resonance imaging. This case highlights the distinctive symptoms associated with IIP and emphasizes the importance of careful neurological examination and advanced neuroimaging techniques for accurate diagnosis.

A Case of Patient with Bilateral Cochleovestibular Function Loss due to Infratentorial Superficial Siderosis: Gyuman Lee, Youngmin Mun, Dae Bo Shim; Res Vestib Sci. 2023;22(3):83-88. Published online September 15, 2023; DOI: https://doi.org/10.21790/rvs.2023.22.3.83; Correction in: Res Vestib Sci 2023;22(4):137

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Abstract PDF: Superficial siderosis (SS) is a rare neurodegenerative condition characterized by hemosiderin deposition in the central nervous system, which sometimes leads to sensorineural hearing loss and vestibular dysfunction. This case report details the diagnosis and treatment of a 63-year-old female patient presenting with a yearlong history of postural instability and recent symptoms of sudden right-sided hearing loss and imbalance. Physical examination and imaging revealed bilateral deafness and infratentorial SS. Treatment, including medication, vestibular exercises, high-dose steroids, and hyperbaric oxygen therapy, led to a significant alleviation of dizziness but no improvement in hearing. This case emphasizes the need for clinicians to consider SS in patients presenting with sudden-onset hearing loss and dizziness, even without prior any medical history or trauma, to accurately identify the underlying cause.

A Case of Delayed Audiovestibulopathy after Posterior Circulation Ischemic Stroke: Hyun Su Lee, Eun Kyung Jeon, Dong Hwan Kwon, Tae Hoon Kong; Res Vestib Sci. 2023;22(3):77-82. Published online September 15, 2023; DOI: https://doi.org/10.21790/rvs.2023.22.3.77

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Abstract PDF: Distinguishing central and peripheral causes of dizziness is vital. A case is presented where a 42-year-old man with a history of posterior circulation ischemic stroke developed acute unilateral vestibulopathy with hearing loss. Clinical examination revealed signs of vestibular dysfunction on the left side. Audiometry confirmed deafness on the left, but imaging ruled out new central issues. The patient was diagnosed with audiovestibulopathy and treated with steroids, antiviral agents, intratympanic injections, and hyperbaric oxygen therapy. Hearing loss persisted, but dizziness improved with vestibular rehabilitation. Poststroke patients should be closely monitored for peripheral complications. Further research should explore the benefits of antiplatelet therapy in vascular-related conditions, even without clear central lesions.

Review

Canal Conversion and Reentry of Otolith in Benign Paroxysmal Positional Vertigo: Jong Sei Kim, Minbum Kim; Res Vestib Sci. 2023;22(3):59-67. Published online September 15, 2023; DOI: https://doi.org/10.21790/rvs.2023.22.3.59

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Abstract PDF: During the treatment process for benign paroxysmal positional vertigo (BPPV) using the canalith repositioning procedure, the otolith can inadvertently enter the semicircular canal instead of the utricle. Canal conversion refers to the situation where the otolith enters a different semicircular canal, while reentry occurs when the otolith returns to the same semicircular canal. The occurrence of a canal conversion can complicate the accurate diagnosis and treatment of BPPV, potentially leading to misdiagnosis and unsuccessful results in the canalith repositioning procedure. In this review, we aim to summarize the incidence, clinical features, and associated risk factors of canal conversion and reentries.

Original Article

Re-fixation Saccade at Video-Head Impulse Test in Patients with Sudden Sensorineural Hearing Loss: Dong Hyuk Jang, Sun Seong Kang, Hyun Joon Shim, Yong-Hwi An; Res Vestib Sci. 2023;22(2):46-51. Published online June 15, 2023; DOI: https://doi.org/10.21790/rvs.2023.22.2.46

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Abstract PDF: Objectives
This study was performed to evaluate characteristics and their prognostic value of video-head impulse test (vHIT) in sudden sensorineural hearing loss (SSNHL) with vertigo.
Methods
Of the 612 patients with a diagnosis of SSNHL from 2010 to 2018, 110 patients (18.0%) with vertigo and 39 patients (6.4%) with vHIT results were recruited. The patients were evaluated for their pure-tone hearing average (at initial, 1-month, and 6-month visit), the presence of re-fixation saccade and gains at vHIT, the canal paresis (CP) at ccaloric test.
Results
Patients with saccade (+) showed higher pure-tone averages than those with saccade (‒) on initial and follow-up audiograms. The improvement in pure-tone averages was less in the saccade (+) group than in the saccade (‒) group. There was no significant difference of hearing recovery between SSNHL patients with normal gain and those with decreased gain. There was no difference of hearing improvement between CP (+) and CP (‒) groups according to the presence of re-fixation saccade.
Conclusions
Concurrent re-fixation saccade at vHIT is a negative prognostic factor of hearing function in SSNHL. Re-fixation saccade in SSNHL may suggest widespread damages to both the cochlea and the vestibule, leading to the poor prognosis.

Review

Light Cupula: Recent Updates: Dong-Han Lee, Chang-Hee Kim; Res Vestib Sci. 2023;22(2):23-33. Published online June 15, 2023; DOI: https://doi.org/10.21790/rvs.2023.22.2.23

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Abstract PDF: Benign paroxysmal positional vertigo (BPPV) is the most common cause of positional vertigo and nystagmus. Direction-changing positional nystagmus (DCPN), which refers to the change in the direction of nystagmus with different head positions, is a well-known characteristic of horizontal semicircular canal BPPV. The supine head roll test is commonly used to diagnose horizontal canal BPPV. However, persistent geotropic DCPN observed during this test cannot be explained by conventional mechanisms of canalolithiasis or cupulolithiasis. The concept of a “light cupula” has been proposed to account for this unique nystagmus. In this review, we summarize the historical background, clinical features and diagnostic methods, presumed mechanisms, and treatment approaches of the light cupula phenomenon based on the available literatures up to date.

Original Articles

Dizziness in Patients with Vestibular Epilepsy: Wankiun Lee, Jae-Moon Kim; Res Vestib Sci. 2023;22(1):7-13. Published online March 13, 2023; DOI: https://doi.org/10.21790/rvs.2023.22.1.7

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Abstract PDF: Objectives
Vestibular epilepsy refers to epilepsy in which vertigo is the sole or main symptom of a seizure. However, epilepsy is rarely considered as a differential diagnosis in patients complaining of dizziness. Here, we reviewed ten cases of vestibular epilepsy and analyzed the dizziness complained by the patient.
Methods
In this study, the medical records of dizziness patients with epileptic discharges observed on electroencephalogram were retrospectively analyzed. Patients who had other obvious causes of dizziness, lacked a description of dizziness, or were not taking antiseizure medications were excluded. We finally recruited 10 patients, and investigated their dizziness characteristic, brain imaging tests, electroencephalograms, and blood test findings.
Results
Patients with vestibular epilepsy usually felt dizzy abruptly while not moving, and often complained of dizziness in the form of spinning around or becoming dazed. Dizziness was short, usually between a few seconds and a few minutes, and the frequency of occurrence was variable, so there was no consistent trend. There were no abnormal findings in blood tests. In brain imaging test, most patients did not show significant abnormalities. The electroencephalographic abnormalities of the patients were mainly observed in the temporal lobe, and the dizziness they complained of improved when they started taking antiseizure medications.
Conclusions
If a patient with dizziness complains of dizziness that occurs suddenly and lasts for a short time, early electroencephalogram should be considered to prevent the diagnosis of epilepsy from being overlooked or delayed.

Clinical Characteristics of Benign Paroxysmal Positional Vertigo Positive on Bilateral Dix-Hallpike Test: Youngrok Jo, Gun Min Lee, Youn Jin Cho, Mi Joo Kim, Minbum Kim; Res Vestib Sci. 2023;22(1):14-18. Published online March 13, 2023; DOI: https://doi.org/10.21790/rvs.2023.22.1.14

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Abstract PDF: Objectives
The purpose of this study is to investigate the clinical characteristics of benign paroxysmal positional vertigo (BPPV) which showed torsional nystagmus on bilateral Dix-Hallpike test, and to analyze the clinical features of pseudo-bilateral BPPV.
Methods
This study is a retrospective chart review of a total of 341 patients diagnosed with BPPV of posterior canal (PC-BPPV). Among them, patients who showed torsional nystagmus on bilateral Dix-Hallpike test were defined as “bilateral DixHallpike positive patients,” who were classified into true- and pseudo-bilateral PC-BPPV group through analysis of nystagmus direction. And pseudo-bilateral PC-BPPV were categorized into two subtypes according to their pathomechanisms. Clinical characteristics including sex, age, underlying vestibular disorders, recurrence and the number of Epley maneuvers were analyzed. Student t-test and Mann-Whitney U-test were used for statistical analysis.
Results
Among 341 patients, 27 patients (7.9%) were “bilateral Dix-Hallpike positive patients”. They received more Epley maneuvers than the group of unilateral PC-BPPV until the resolution of nystagmus (2.3 vs. 1.4, p＜0.001). Fifteen patients out of 27 were diagnosed with pseudo-bilateral PC-BPPV, who were classified into two subtypes according to their pathomechanisms. The number of Epley maneuvers was not different between true- and pseudo-bilateral PC-BPPV.
Conclusions
Patients with pseudo-bilateral PC-BPPV were common among “bilateral Dix-Hallpike positive patients.” For their better treatment, understanding of possible pathophysiology, accurate Dix-Hallpike test and detailed analysis of nystagmus direction are necessary.

Review

Treatment in Benign Paroxysmal Positional Vertigo: Factors that Affect Successful Treatment Outcome: Dae Bo Shim; Res Vestib Sci. 2023;22(1):1-6. Published online March 13, 2023; DOI: https://doi.org/10.21790/rvs.2023.22.1.1

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Abstract PDF: Benign paroxysmal positional vertigo (BPPV) is the most common etiology of benign vestibulopathy. Various treatments for BPPV have been developed, and appropriate treatments for each subtype of BPPV have been provided and used in accordance with clinical practice guidelines published by the American Academy of Otorhinolaryngology-Head and Neck Surgery in 2008 and 2017. Although many therapeutic maneuvers have been reported to show high success rates in the treatment of BPPV patients, some cases are not effective even by appropriate therapeutic maneuvers. This article reviews various factors affecting the successful treatment of BPPV patients.

Original Article

The Head-Bending Test in Posterior Semicircular Canal Benign Paroxysmal Positional Vertigo: Sol-lim Choi, Hyun-Sung Kim, Jae-Hwan Choi, Eun Hye Oh; Res Vestib Sci. 2022;21(4):99-103. Published online December 15, 2022; DOI: https://doi.org/10.21790/rvs.2022.21.4.99

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Abstract PDF: Objectives
This study aimed to investigate clinical significance of a head-bending test in benign paroxysmal positional vertigo (BPPV) involving the posterior semicircular canal (PC-BPPV).
Methods
We retrospectively recruited 256 patients with unilateral PC-BPPV between January 2016 and December 2021, and assessed the clinical characteristics of patients showing head-bending nystagmus (HBN).
Results
Of 256 patients, 138 (53.9%) showed HBN. Most patients (n=136, 98.6%) had downbeat nystagmus with (n=38) or without (n=98) torsional component. The remaining two patients had pure upbeat and torsional nystagmus, respectively. The torsional component was directed to the contralesional side in all. Between patients with and without HBN, there were no significant differences in clinical characteristics such as age, lateralization, types of BPPV (canalolithiasis or cupulolithiasis), and success rate of repositioning maneuver.
Conclusions
Head-bending test may be useful in predicting the diagnosis and lateralization of PC-BPPV.

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