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Benign Paroxysmal Positional Vertigo Involving Multiple Semicircular Canals
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Ji Yeon Chung, Hyo Jung Kim, Ji Soo Kim
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Res Vestib Sci. 2014;13(1):1-6.
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 Abstract
- Even though benign paroxysmal positional vertigo (BPPV) mostly affects a single semicircular canal (SCC), BPPV simultaneously involving more than one SCC is not rare. This multi-canal BPPV may either involve the same canals on both sides or simultaneously affect different canals on the same or on both sides. Since the SCCs can be involved in various combinations in one or both ears, multi-canal BPPVs pose diagnostic and therapeutic challenges. The different patterns of nystagmus induced during each positional maneuver should be differentiated from positional vertigo and nystagmus due to central lesions. It remains unknown which canal should be treated first and which maneuver should be adopted for multi-canal BPPVs. Furthermore, the optimal interval from treatment of a canal to another should be determined. The response to canalith repositioning maneuvers and recurrences do not differ between multi- and single canal BPPVs in spite of more frequent involvement of multiple canals in traumatic cases.
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Superior Semicircular Canal Dehiscence Syndrome Presenting with Sudden Deafness and Vertigo after Trauma
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Seong Il Kang, Sunjoo Lee, Ji Soo Kim, Ja Won Koo
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Res Vestib Sci. 2013;12(4):132-135.
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Abstract
- Superior semicircular canal dehiscence syndrome (SCDS) is characterized by cochleovestibular hyper-responsiveness symptoms including sound- and pressure- evoked vertigo and oscillopsia, autophony, hyperacusis and ear fullness. The typical audiometric feature of SCDS is known as conductive hearing loss at low frequency. A 43-year-old man presented with unilateral sudden deafness after several events of heading during soccer game. High-resolution temporal bone computed tomography revealed a dehiscence of superior canal encased by superior petrous sinus. We reviewed audio-vestibular findings in this patient and speculated potential pathogenic mechanisms of sudden deafness in SCDS with literature review.
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Asymmetric Audiovestibular Dysfunction in Patients With Systemic Aminoglycoside Treatment
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Jae Hong Park, Yoon Chan Rah, Ji Soo Kim, Ja Won Koo
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Res Vestib Sci. 2013;12(2):62-66.
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Abstract
- Since the characteristics of aminoglycoside ototoxicity is typically bilaterally symmetric progression of cochlea-vestibular dysfunction, a unilateral involvement has rarely been reported. However, ototoxicity can be asymmetric or focal after systemic aminoglycoside treatment. The authors report 2 cases of asymmetric or focal audiovestibular deficits in patients treated with systemic aminoglycoside. In such cases, further investigations are also necessary to rule out other possible causes of unilateral sensorineural hearing loss such as cerebellopontine angle tumors.
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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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- 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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Can Nitroglycerin Differentiate Benign Recurrent Vertigo From Vestibular Migraine? A Preliminary Study
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Jong Wook Shin, Seong Hae Jeong, Ji Eun Oh, Ae Young Lee, Jae Moon Kim, Ji Soo Kim
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Res Vestib Sci. 2012;11(1):8-13.
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- Background and Objectives: Nitroglycerin (NTG), a donor of nitric oxide, is known to provoke migraine attacks in patients with migraine. However, this effect was not explored in patients with benign recurrent vertigo (BRV). To infer the mechanism of BRV, we evaluated provocative effects of NTG in patients with vestibular migraine (VM) and BRV compared with normal controls. Materials and Methods: Thirteen patients with recurrent vertigo, 8 with VM and 5 with BRV, and 5 healthy controls received intravenous infusion of 0.5 μg/kg/min NTG over 20 minutes. Headache intensity (visual analog scale) and associated symptoms were recorded at baseline and every 10 minutes for an hour. And the subjects were also asked to complete a headache diary every hour for another 12 hours. Results: In contrast to normal controls (2/5, 40%, p=0.035) and the patients with BRV (1/5, 20%, p=0.007), all patients with VM (8/8, 100%) had migraine attacks after NTG injection. However, there was no difference in the proportion of the patients with migraine attacks after NTG injection between normal controls and the patients with BRV. Conclusion: In contrast to the patients with VM, patients with BRV are not sensitive to nitric oxide. These results suggest that the pathophysiology of BRV may be different from that of VM.
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Effects of Galvanic Stimulation on Spontaneous Nystagmus in Meniere’s Disease and Vestibular Neuritis: A Preliminary Study
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Seong Hae Jeong, Ji Soo Kim
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Res Vestib Sci. 2010;9(2):64-69.
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- Background and Objectives Galvanic vestibular stimulation (GVS) is known to induce nystagmus, ocular torsion, a tilt of subjective visual vertical, and perceptual and postural shift. The aim of this study was to compare the findings of GVS among the patients with spontaneous nystagmus (SN) caused by Meniere’s disease (MD) or vestibular neuritis (VN).
Materials and Methods Three-dimensional video-oculography was performed without fixation in 4 patients with MD and 2 with VN, as diagnosed by history, independent vestibular function tests and neuroimaging. We recorded the eye-movements in response to bilateral, bipolar, and surface GVS (2.5~3 mA) for 30 seconds, and analyzed mean slow phase velocity of SN.
Results Of the 4 patients with MD, two exhibited a suppression of the left beating SN during anode stimulation of left mastoid and an augmentation of the nystagmus during cathode stimulation of left mastoid. The same patterns of galvanic modulation were observed in the other 2 patients with right beating SN due to MD. In contrast, the patients with VN showed an absent or decreased response to GVS.
Conclusion In MD, the responses to GVS were preserved while the responses were impaired in VN. These results suggest that the irregular vestibular fibers, which are sensitive to GVS, are relatively spared in MD. In contrast, both regular and irregular fibers appear to be damaged in VN. GVS may be helpful in discriminating MD from VN, especially when the patients presented without auditory symptoms.
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The Effect of Serum Uric Acid in Generating Idiopathic Benign Paroxysmal Positional Vertigo
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Seong Hae Jeong, Ji Soo Kim
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Res Vestib Sci. 2010;9(1):27-31.
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- Background and Objectives The causative role of serum uric acid has been controversial in Benign paroxysmal positional vertigo (BPPV). The aim of this study was vto determine the role of serum uric acid in developing idiopathic BPPV.
Materials and Methods We recruited 168 consecutive patients with a confirmed diagnosis of idiopathic BPPV. The patients comprised 116 women (age range: 29~70 years, mean±SD: 55.8±9.7 years) and 52 men (age range: 32~70 years, mean±SD: 55.2±10.9 years). The serum uric acid levels of the patients were compared with those of 194 controls (age range: 20~70 years, mean±SD: 55.5±7.8 years) without a history of dizziness.
Results The serum uric acid levels were decreased in patients with BPPV compared with those in normal controls (4.8±1.3 vs 5.3±1.3, p=0.001). However, multiple logistic regression analyses adjusted for age, sex, alcohol, smoking, hyperphosphatemia and osteopenia/osteoporosis did not demonstrate that the hypouricemia is an independent risk factor for BPPV.
Conclusion This study suggests that serum uric acid level is not a risk factor for developing idiopathic BPPV.
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Clinical Features and Treatment Pattern of Migrainous Vertigo in Korea: A Nationwide Prospective Multicenter Study
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Seong Ki Ahn, Kyusik Kang, Ja Won Koo, Kyu Sung Kim, Beom Gyu Kim, Byung Kun Kim, Ji Soo Kim, Kyoung Ho Park, Shi Nae Park, Eun Ho Park, Hong Ju Park, Jae Yong Byun, Myung Whan Suh, Ki Bum Sung, Sun Young Oh, Chung Ku Rhee, Tae Kyeong Lee, Seong Hae Jeong, Won Ho Chung, Chang Il Cha, Sung Won Chae, Eui Kyung Goh
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Res Vestib Sci. 2009;8(2):122-131.
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- Background and Objectives It is being increasing recognized that the morbidities of migraine and balance disorders are interrelated. In fact, migrainous vertigo (MV) is one of frequent causes of recurrent vertigo in patients presenting to specialized dizziness clinics. Nevertheless, not many studies have reported clinical manifestations and treatment. Therefore, the aim of study was designed to assess clinical features and treatment patterns by a nationwide multicenter study. Materials and Methods Patients between 9 and 74 years of age who visited 17 Korean tertiary referral centers and 1 clinic from February to March 2009 were investigated using two forms of questionnaires. Results Overall, 318 patients with MV were enrolled. MV was responsible for ~8.45% of visits to the specialized dizziness clinics. One hundred seventy-five of these patients had definite MV and were included in assessing the clinical features. Vertigo characteristics of patients with definite MV were various. Vertigo was regularly as-sociated with headache in 87% of the patients. The duration of vertigo ranged from seconds to days. For the treatment patterns, an acute and prophylactic therapies were carried in most clinics. There were no differences in either acute or prophylactic therapies between department of neurology and otorhinolaryngology. Conclusions The results of this study suggest that MV the clinical features of MV also varies in Korea. In addition, most clinics provide similar patterns of practice in treatment for MV. The syndrome of MV deserves further research activity as it is relatively common and clinically relevant.
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A Case of Apogeotropic Positional Nystagmus Associated With Anti-GD1b IgG Antibody
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Seong Hae Jeong, Gun Sei Oh, Dong Ick Shin, Ji Soo Kim
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J Korean Bal Soc. 2008;7(1):73-76.
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- The binding of anti-GD1b IgG antibody to the cerebellar granular area or spinocerebellar Ia fibers in the peripheral nerves may cause the prominent cerebellar ataxia, mild quadriparesis and sensory dominant neuropathy. A 31-year woman presented with severe cerebellar ataxia and prominent apogeotropic positional nystagmus/vertigo. Increased anti-GD1b antibody IgG in her serum was noted. 18F-flurodeoxyglucose positron emission tomography (FDG-PET) showed decreased uptake in cerebellum. It is the first case of central positional nystagmus with anti-GD1b IgG antibody.
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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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Resolution of Canal Paresis after Treatment in Benign Paroxysmal Positional Vertigo of the Horizontal Canal
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Kyung Tae Park, Myung Whan Suh, Chae Seo Rhee, Ji Soo Kim, Ja Won Koo
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J Korean Bal Soc. 2007;6(2):217-221.
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- Canal paresis in patients with benign paroxysmal positional vertigo (BPPV) has been variously reported from 26 to 50%. In such cases, BPPVs are developed secondary to accompanying vestibulopathy or other underlying inner ear diseases. Also the side of canal paresis is regarded as involved ear in the lateralization of horizontal canal BPPV (HC-BPPV), in which lateralization is sometimes ambiguous just by Eward’s second law. In this case, authors report a woman who had HC-BPPV and pathologic canal paresis which resolved after canalith repositioning. This case may imply that dislodged particles block the endolymphatic flow resulting canal paresis.
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Tilt Suppression of the Post-rotatory Nystagmus in Cerebellar Nodular Lesions
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Sun Young Oh, Kwang Dong Choi, Jung Eun Kim, Ja Won Koo, Ji Soo Kim
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J Korean Bal Soc. 2007;6(2):161-166.
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- Background and Objectives: Head tilt at the end of step rotation about a vertical axis decreases the time constant (TC) of the post-rotatory nystagmus, which is known as tilt-suppression of the vestibulo-ocular reflex (VOR). Tilt suppression of the VOR is mediated by the cerebellar nodulus and ventral uvula and is eliminated after surgical ablation of those structures. However, studies on the tilt suppression of the VOR have been sparse in humans with cerebellar lesions.
Materials and Methods: Five patients with circumscribed cerebellar lesions involving the nodulusor ventral uvula underwent recording of spontaneous and positional nystagmus, and the VOR. To evaluate tilt suppression of the VOR, the participants pitched their head forward at the end of step rotation about a vertical axis both in the clockwise and counter-clockwise directions.
Results: The VOR gain was increased in a patient with infarction in the territory of the medial posterior inferior cerebellar artery while the gain of visually enhanced VOR was normal in all the patients. The time constants of perand post-rotatory nystagmus was increased in a patient with increased VOR gain and the tilt suppression of the post-rotatory nystagmus was impaired in two patients, either uni- or bilaterally. Spontaneous downbeat and central positional nystagmus were frequently accompanied.
Conclusions: Nodular lesion may impair tilt suppression of the VOR. Measurement of tilt suppressive effect of the VOR may provide a valuable tool for evaluating the nodular dysfunction.
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Novel Mutation in FRMD7 Gene in X-linked Congenital Nystagmus
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Sun Young Oh, Byoung Soo Shin, Man Wook Seo, Chang Seok Ki, Jeong Min Hwang, Ji Soo Kim
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J Korean Bal Soc. 2007;6(2):155-160.
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- Background and Objectives: Congenital nystagmus (CN) is an ocular oscillation that usually manifests during early infancy. To report a novel mutation in FERM domain containing 7 (FRMD7) gene in a Korean family with CN.
Materials and Methods: Genomic DNA was prepared from peripheral blood leukocytes and direct sequencing of the entire coding and adjacent intronic regions was performed to detect sequence variation of FRMD7 gene, where mutations were found recently in patients with familial CN. The family showed an X-linked pattern of inheritance without father-to-son transmission.
Results: Three family members with CN exhibited two sequence variations which were a novel mutation (c. 875T>C; Leu292Pro) and a polymorphism (c. 1403G>A; Arg468His, dbSNP rs#6637934). The proband was hemizygous for both variations and his mother and maternal grandmother were heterozygous carriers.
Conclusion: This study provides an additional evidence for mutations in FRMD7 as a common cause of X-linked CN and expands its mutation spectrum.
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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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Bilateral Inversion of Initial Nystagmus in Benign Paroxysmal Positional Vertigo of Horizontal Canal
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Myung Whan Suh, Sang Wook Kim, Min Hyun Park, Ji Soo Kim, Ja Won Koo
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J Korean Bal Soc. 2006;5(2):299-306.
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- Horizontal canal benign paroxysmal positional vertigo (HC-BPPV) is characterized by direction-changing nystagmus of the horizontal component induced by lateral head turning in supine position. Yet, some patients with HC-BPPV show nystagmus inversion during head turning to one side. And, mostly, the nystagmus started in a geotropic direction and the inversion was observed only when the head is turned to the lesion side. Reversal of the clot movement in the canal and sensory adaptation were suggested as the hypothesis for such finding. However, bilateral inversion of geotropic nystagmus into apogeotropic nystagmus in HC-BPPV has seldom been described before. In this paper, the authors presented the characteristic features and progression during reposition of a patient with bilateral nystagmus inversion and speculated its mechanisms.
Key Words : Positional vertigo, Semicircular canal, Diagnosis, Nystagmus
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Horizontal Canal Benign Paroxysmal Positional Vertigo in Caloric Dead Labyrinth
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Jae Jin Song, Yong Hwi Ahn, Ji Soo Kim, Ja Won Koo
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J Korean Bal Soc. 2006;5(1):63-69.
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- The presence of functioning semicircular canal is regarded as a prerequisite for the development of benign paroxysmal positional vertigo (BPPV) since BPPV is irritative vestibulopathy. However, authors experienced a case of horizontal semicircular canal BPPV in which bithermal caloric test and ice water test were compatible with complete canal paralysis. Forty eight year-old man visited ER for sudden onset of vertigo and right hearing loss developed 3hours and 4 hours ago, respectively. Vertigo was vaguely complained and was floating in nature, which was aggravated with head position change. Initial audiometry showed 110 dB on pure tone averages. Positional test showed horizontal geotropic direction changing positional nystagmus and it was compatible with canalolithias of right horizontal semicircular canal. The results of initial and follow up bithermal caloric tests and ice water test on supine and prone
position were compatible with right side complete canal paralysis. This case implies that caloric dead labyrinth may not represent complete absence of the lateral semicircular canal function and also BPPV can be developed even in a condition with minimal functional remaining.
Key Words : Positional vertigo, Caloric test
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A Promotive Effect of Low Level Laser on Hair Cell Viability in Postnatal Organotypic Culture of Rat Utricles
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Sun Young Oh, Kwang Dong Choi, Jae Moon Kim, Jei Kim, Seong Ho Park, Ji Soo Kim
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J Korean Bal Soc. 2006;5(1):35-43.
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- Background
and Objectives: To culture and maintain mammalian hair cells is still a big challenge. In this study, long-term organotypic culture of rat utricular maculae was established to study vestibular hair cell. The effects of low level laser on hair cell viability in postnatal organotypic culture of rat utricles were investigated.
Materials and Method: Uticular explants were prepared from postnatal 2 to 7 rats and cultured. To improve hair cell survival, the utricles were irradiated daily with low level laser. Whole-mount utricles were stained with FM1-43 which is known to be an efficient marker to identify live hair cells in cultured tissues. Such cells visualized directly through tissue culture dish with cover glass bottom by Confocal laser scanning microscope at specific time points.
Results
The explanted utricular hair cells were cultured for up to 31 days in in vitro culture system. In low level laser irradiation group, utricular hair cells were more survived at 24 DIV and 31 DIV.
Conclusion
These results suggest that low level laser promotes hair cell viability in utricular explants.
Key Words : Organotypic culture, Low level laser, FM 1-43, Utricle
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Bell’s Palsy associated with Acute Vestibulopathy
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Ja Won Koo, Jae Jin Song, Dong Yeop Chang, Ji Soo Kim
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J Korean Bal Soc. 2005;4(2):259-263.
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- Bell’s palsy is acute idiopathic peripheral facial nerve palsy which is diagnosed after all the possible causes are ruled out. Several symptoms and signs of polyneuropathy, such as hypesthesia of cranial nerve IX or V, vagal motor weakness, retroauricular pain, and hearing impairment were frequently accompanied with Bell’s palsy. However, association of vertigo has been rarely reported, and moreover, associated vestibulopathy was not characterized in detail in those cases. We report a 35 year-old male patient with Bell’s palsy accompanying acute peripheral vestibular loss, which eventually evolved to benign paroxysmal positional vertigo.
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Analysis of Parameters of Vestibular-Evoked Myogenic Potentials in Sudden Sensorineural Hearing Loss without Vertigo
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Min Hyun Park, Woo Jin Jeong, Jae Jun Song, Ji Soo Kim, Ja Won Koo
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J Korean Bal Soc. 2005;4(2):206-211.
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- Background
and Objective: Vestibular evoked myogenic potentials (VEMP) has been promoted as a means of assessing the integrity of saccular function. Even though sacculospinal reflex may not be influenced by abnormality of cochlear pathway, saccule is closely related with cochlea in its embryological development and also in geographic location. So authors hypothesized the presence of functional alterations of saccule in patients with sudden sensorineural hearing loss who do not complain of vertigo, since saccular dysfunction may not induce subjective vestibular symptoms or signs. Authors tested saccular function in those patients using VEMP and analyzed the parameters according to other clinical indicators.
Materials and Method: From July to September 2005, 22 patients who diagnosed with unilateral sudden sensorineural hearing loss without vertigo were enrolled. The patients who had vertigo as initial symptom or showed spontaneous nystagmus were excluded. All patients received conventional audiometry, tone-burst VEMP test, and caloric test. We analyzed P13 and N23 latency, interpeak amplitude and asymmetric ratio of amplitude. The patients divided to complete hearing recovery, partial recovery, and no response group according to treatment outcome. The correlation between parameters and treatment result was analyzed.
Results
In 2 out of 22 patients (9.1%), VEMP waves were not detected. There was no latency delay in affected ear. But the interpeak amplitude of the affected ear was significantly smaller than that of healthy side (paired t test, p=0.02). Patients who did not respond to treatment showed smaller interpeak amplitude than those who showed complete recovery.
Conclusion
Most patients of idiopathic sudden sensorineural hearing loss without vertigo seem to show normal VEMP waves. But some parameters regarding amplitude had abnormal findings in affected ear. Further studies with larger sample size seem to be necessary to elucidate such outcomes.
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Jerky Seesaw Nystagmus in Isolated Internuclear Ophthalmoplegia
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Kyungmi Oh, Jae Hong Chang, Kun Woo Park, Dae Hie Lee, Kwang Dong Choi, Ji Soo Kim
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J Korean Bal Soc. 2005;4(1):49-52.
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- The authors report jerky seesaw nystagmus, extorsional downbeating in the right eye and intorsional upbeating in the left eye, in a patient with right internuclear ophthalmoplegia (INO). This pattern of nystagmus may occur by disrupting pathways from contralateral posterior and anterior semicircular canals by a lesion in the medial longitudinal fasciculus. Depending on damage to the pathways from contralateral vertical canals, various patterns of dissociated torsional-vertical nystagmus may accompany INO.
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A Case of Contralateral Benign Paroxysmal Positional Vertigo after Mastoidectomy
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Sung Lyong Hong, Ji Soo Kim, Ja Won Koo
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J Korean Bal Soc. 2005;4(1):45-48.
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- hors suggest plausible mechanisms of the contralateral side BPPV after mastoid surgery as follows. Surgical position during mastoid surgery (contralateral ear down) and postoperative bulky mastoid compressive dressing usually kept the patient’s head to the contralateral side can be precipitating factors for migration of detached particles into the semicircular canal of dependent position. Anyway, appropriate differential diagnosis and management plans should be prompted using bed side vestibular evaluation, since serious irreversible inner ear complications are more frequent cause of postoperative vertigo than BPPV.
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Convergence-Retraction Nystagmus: Analysis with 3-dimensional Oculography
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Ji Soo Kim, Kwang Dong Choi, Sun Young Oh
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J Korean Bal Soc. 2005;4(1):5-12.
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- Background
and Objectives : Convergence-retraction oscillations are rhythmic or arrhythmic jerks of dysjunctive eye movements associated with backward displacement of the eyeballs during the convergence phase. Oscillations in convergence-retraction oscillations have been proposed to be consisted of opposed adducting saccades immediately followed by slow abducting glissades without latency. However, dynamic characteristics of convergence oscillations accompanying retraction have not been studied, and pathomechanism of these eye movements remains to be elucidated. This study was to get insights on the pathomechanisms of convergence-retraction oscillations by using 3-dimensional recording of eye movements. In particular, we intended to clarify whether the nystagmus originates from instability of vergence eye movement or of saccades.
Materials and Method : Seven consecutive patients with convergence-retraction oscillations were recruited. All the patients received full neurological and neuro-ophthalmological evaluation by the senior author. Some of the patients underwent 3-dimensional recordings of convergence-retraction oscillations with video-oculography or magnetic search coil technique.
Results
: Wave forms of convergence-retraction oscillations were varied. The onset of convergent eye movements was either synchronous or asynchronous between both eyes. The initial directions of eye movement was same (conjugate) or opposite (disjunctive). In some, vergence eye movements occurred only in one eye (unilateral). Convergence phase of one eye was commonly consisted of multiple steps while the other eye attained final position with a single step. The following divergent eye movements commonly overshoot the orbital midposition and were followed by correcting convergent eye movements. The velocity-amplitude relationship of convergent eye movements, which was analyzed in typical pairs of vergence oscillations, did not differ between both eyes. Divergent eye movements are slower than convergent eye movements. The both convergent and divergent eye movements were slower than the microsaccades of similar amplitudes.
Conclusion
: Quantitative analyses of convergence-retraction oscillations revealed various patterns of wave forms. The amplitude-velocity relationships of the disjunctive eye movements suggest that the slowed saccades may be due to co-contraction of the agonist and antagonist, or due to enhanced vergence eye movements by the accompanying saccades.
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Possible Mechanism of Seesaw Nystagmus in Internuclear Ophthalmoplegia
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Ji Soo Kim, Kwang Dong Choi, Ja Won Koo, Kyungmi Oh, Jae Hong Chang, Kun Woo Park, Dae Hie Lee, Gyu Cheol Han
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J Korean Bal Soc. 2004;3(2):413-416.
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Abstract
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- The authors report jerky seesaw nystagmus, extorsional downbeating in the ipsilesional eye and intorsional upbeating in the contralesional eye, in a patient with internuclear ophthalmoplegia (INO) from focal pontine lesion. This pattern of nystagmus may occur by disrupting pathways from contralateral posterior and anterior semicircular canals by a lesion in the medial longitudinal fasciculus. Depending on the pathways involved, various patterns of dissociated
torsional-vertical nystagmus may accompany INO.
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Vestibular Evoked Myogenic Potential Generated by 500 Hz Tone Burst in Unilateral Peripheral Vestibulopathy
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Ja Won Koo, Dong Hwan Roh, Chang Hee Kim, Jin Young Kim, Ji Yeon Yu, Kwang Dong Choi, Ji Soo Kim
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J Korean Bal Soc. 2004;3(2):356-361.
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Abstract
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- Background
and Objectives : Vestibular evoked myogenic potential (VEMP) has become a valuable diagnostic tool evaluating the integrity of sacculocollic reflex and has been done using click sound in most previous clinical trials. This study aims to investigate VEMP responses generated by 500 Hz tone burst in unilateral peripheral vestibulopathy and compare the response with caloric test and subjective visual vertical (SVV).
Materials and Method : Clinical records of 37 patients (18 men and 19 women, aged 14-80 years) with unilateral peripheral vestibulopathy were reviewed. Diagnoses were Meniere's disease (n=13), vestibular schwannoma (n=4) and acute peripheral unilateral vestibulopathy (n=20). They underwent 500Hz tone burst VEMP, caloric test and SVV test. Thirteen healthy volunteers (26 ears, 8 men and 5 women, 25~41 years) with normal hearing were enrolled as control group.
Results
: VEMP response was present in every control ear using 500 Hz tone burst stimuli. In Meniere's disease, VEMPs were positive in 57% (4/7) of patients with abnormal caloric response group and 83% (5/6) with normal caloric response. In acute peripheral vestibulopathy, VEMPs were positive in 47% (9/19) of patients with abnormal caloric response, 0% (0/1) with normal caloric response. The average of CP (canal paresis) in positive VEMP group was
62.4% and that in negative VEMP group was 48.2% (P>0.05).
Conclusion
: Reliable and reproducible test results can be obtained using 500 Hz tone burst stimuli. VEMP results were not in concordance with other vestibular tests, which reflects the dynamic process of dizziness and variable extent of pathology in each case.
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Traumatic Perilymphatic Fistula Presenting with Direction-Changing Positional Nystagmus
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Ja Won Koo, Si Whan Kim, Ji Soo Kim, Sung Wha Hong
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J Korean Bal Soc. 2004;3(1):173-176.
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Abstract
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- Diagnosis of perilymphatic fistula (PLF) is considered in the patient presenting hearing loss associated with ataxia
after penetrating injury of the tympanic membrane. PLF accompanies mixed type hearing loss and paralytic nystagmus.
If audiovestibular symptoms and signs are not definite for those patients, in whom PLF is highly suspicious, they can
be induced by affected ear down position. The direction of nystagmus induced by position change was reported either
toward or away from the affected ear. But the direction changing nature has not been noted in the previous literature.
We report on a case of traumatic PLF presented with direction changing positional nystagmus and discuss the possible
mechanism involved in this case.
Key Words : Positional nystagmus, Perilymphatic fistula
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Central Positional Nystagmus from Focal Brain Lesion
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Ja Won Koo, Kwang Dong Choi, So Young Moon, Seong Ho Park, Ji Soo Kim
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J Korean Bal Soc. 2004;3(1):129-135.
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Abstract
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- Department of Otolaryngology, Head and Neck Surgery1, and Neurology2, Seoul National University Bundang Hospital,
Seoul National University College of Medicine, Seongnam, Korea
Background and Objectives : Central positional nystagmus is induced by positional changes from brainstem or
cerebellar lesions. Differentiation central from peripheral positional nystagmus is important in clinical practice. To
delineate characteristics of the positional nystagmus observed in central lesions, we analyzed the parameters of
positional nystagmus from focal brain lesions.
Materials and Methods : Ten patients with central positional nystagmus were recruited from the dizziness clinic
of Seoul National University Bundang Hospital. All the patients had focal brainstem or cerebellar lesions documented
by magnetic resonance imaging. The nystagmus was observed with and without fixation by using Frenzel glasses or
Video Goggles. The nystagmus was videotaped or recorded with video-oculography. Provoking positional maneuvers,
direction, latency, duration, phase reversal, and fatigue phenomenon of the nystagmus were analyzed.
Results
: Of the 10 patients, seven had infarctions in the lateral medulla or inferior cerebellum while two
experienced cerebellar hemorrhage and remaining one showed a compression of the ventrolateral medulla by cavernous
malformation of the vertebral artery. The directions of the positional nystagmus were variable depending on the lesions
and provoking maneuvers. Most patients exhibited direction-changing nystagmus without latency, direction-reversal and
fatigue phenomenon. However, some of the patients also showed patterns of nystagmus characteristic of peripheral
positional nystagmus. In two of the four patients with infarction in the territory of medial posterior inferior cerebellar
artery, the positional nystagmus was the only abnormal findings.
Conclusions
: Central positional nystagmus may share many characteristics with peripheral type of positional
nystagmus. In individual cases, the patterns of nystagmus should be interpreted with caution in differentiating central
from peripheral positional nystagmus. Considering the isolated positional nystagmus in some patients with caudal
cerebellar lesions, systematic positional maneuvers should be applied to all the patients with vertigo
Key Words : Positional nystagmus, Medulla, Cerebellum
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Ocular Contrapulsion in Medial Medullary Infarction
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Ji Soo Kim, So Young Moon, Seon Mi Jeong, Moon Ku Han, Seong Ho Park
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J Korean Bal Soc. 2003;2(2):227-230.
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Abstract
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- 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.
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Tonic inward and downward deviation of the eye
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Kwang Dong Choi, Dae Soo Jung, Ji Soo Kim
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J Korean Bal Soc. 2003;2(1):133-137.
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Abstract
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- Background
Tonic inward and downward deviation of the eyes ('peering at the tip of the nose') is regarded as a unique feature of thalamic hemorrhage, but the mechanisms of this ocular finding remain obscure.
Objective: To report on four patients who showed tonic inward and downward deviations of the eyes from either brainstem or thalamic lesions, and to discuss the possible mechanisms involved.
Design: Case report
Setting: Secondary and tertiary referral hospitals
Results
One patient developed alternating esotropia with downward ocular deviation from thalamic hemorrhage compressing the midbrain. Two patients showed multiple infarctions in the territory of the posterior circulation with or without the involvement of the thalamus. Another patient had lateral pontine hemorrhage extending up to the midbrain tegmentum. Ocular bobbing preceded or accompanied tonic ocular deviation in three patients.
Conclusion
Tonic inward and downward deviation of the eye may develop in thalamic or brainstem lesions. Irritation or destruction of the neural structures involved in the vergence and vertical gaze may cause this ocular sign in mesodiencephalic lesions. Skew deviation and esotropia from abduction deficit may be involved in some patients. Ocular bobbing and tonic downward deviation may share a common pathophysiology.
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Positional Downbeating Nystagmus : Tips from the Transitions
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Ji Soo Kim
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J Korean Bal Soc. 2002;1(2):235-239.
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Abstract
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- Objective : To describe transitions of positional downbeating nystagmus (PDN) to or from the benign positional vertigo (BPV) involving the posterior (PC) or horizontal semicircular canal (HC). Background : PDN occasionally occurs during Hallpike maneuver, and has been ascribed to BPV involving the anterior semicircular canal (AC-BPV).
Method
: Of the 168 patients diagnosed as having BPV in the Dizziness Clinic of Cheju National University Hospital over the past 2 years, three showed transitions of PDN which occurred during Hallpike maneuver. All the patients received full neurotological examinations. The diagnosis of BPV was based on the typical nystagmus concurrent with vertigo elicited by positional maneuvers. The nystagmus was observed by using Frenzel glasses. Nystagmus was also analyzed by using a video camera or video-oculography, as needed.
Result
: Two patients initially presented with torsional downbeating nystagmus during Hallpike maneuver. The torsional component beat toward the uppermost ear. Both patients later developed the PC or HC type of BPV in the uppermost ear. Another patient developed torsional upbeating nystagmus during Hallpike maneuver, consistent with right PC-BPV, following a motor vehicle accident. After Epley maneuver, the nystagmus was transformed into PDN which was observed during Hallpike maneuver to either side and during central head hanging. During Hallpike maneuver, the PDN was more prominent when the involved ear was lowermost.
Conclusion
: These transitions suggest that AC-BPV may involve the uppermost or lowermost ear during Hallpike maneuver. In patients with AC-BPV, the direction of torsional nystagmus may play a crucial role in deciding the affected ear during Hallpike maneuver.
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