Research in Vestibular Science

Case Reports

Horizontal nystagmus with velocity-increasing waveforms in delayed post-hypoxic leukoencephalopathy: a case report: Eugene Jung, Suk-Min Lee, Seo-Young Choi, Kwang-Dong Choi; Res Vestib Sci. 2024;23(3):111-113. Published online September 15, 2024; DOI: https://doi.org/10.21790/rvs.2024.016

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Abstract PDF Supplementary Material: Abnormal eye movements in unconscious patients serve as crucial diagnostic instruments, offering insights into the function of the central nervous system. Understanding these movements can aid in diagnosing the cause of unconsciousness, localizing brain lesions, and predicting outcomes. We report a patient who presented with spontaneous horizontal nystagmus unaffected by light in delayed post-hypoxic encephalopathy. Video-oculography showed exponentially increasing slow phases, with an amplitude ranging from 3° to 9° and a frequency of 0.5 Hz. Based on the results of oculography and neuroimaging, persistent horizontal nystagmus in our patient may be ascribed to an unstable neural integrator, possibly caused by disrupted cerebellar feedback mechanisms for horizontal gaze holding.

Fluctuating high-frequency hearing loss with vertigo: is it Menière’s disease? A case report: Minho Jang, Dong-Han Lee, Jiyeon Lee, Chang-Hee Kim; Res Vestib Sci. 2024;23(3):106-110. Published online September 15, 2024; DOI: https://doi.org/10.21790/rvs.2024.011

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Abstract PDF Supplementary Material: This study describes an unusual case of fluctuating unilateral high-frequency hearing loss with vertigo resembling Menière’s disease. The current diagnostic criteria for definite Menière’s disease include audiometrically documented low- to medium-frequency sensorineural hearing loss on at least one occasion before, during, or after an episode of vertigo. This case presented a diagnostic dilemma. Brain MRI was nonspecific, and a bithermal caloric test showed unilateral weakness of 44% on the affected side. The results of electrocochleography and cervical vestibular evoked myogenic potential tests were within the normal ranges. Persistent geotropic or ageotropic positional nystagmus was observed during each vertigo attack; the mechanism underlying this characteristic nystagmus needs further investigation.

Original Articles

Saccadic oscillations as a possible indicator of dizziness due to choline esterase inhibitors: an observational study with video-oculography: Ileok Jung, Moon-Ho Park, Ji-Soo Kim; Res Vestib Sci. 2024;23(3):101-105. Published online September 15, 2024; DOI: https://doi.org/10.21790/rvs.2024.015

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Abstract PDF Supplementary Material: Introduction: Cholinesterase inhibitors (ChEIs) are widely used to treat mild to moderate Alzheimer disease and vascular dementia. Even though dizziness due to medication of ChEIs has been ascribed to adverse effects on the cardiovascular or central nervous system, the mechanisms remain unclear and objective indicators are not available.
Methods
We recorded the eye movements using video-oculography in three patients who developed dizziness and unsteadiness after initiation or increment of ChEI, donepezil (Aricept).
Results
The patients showed frequent saccadic oscillations that improved after discontinuation of ChEI.
Conclusions
Frequent saccadic oscillations may be an indicator of dizziness in patients taking ChEIs.

Comparison of the outcomes of treatment with an oral diuretics with steroid and steroid only for acute low-tone hearing loss: a prospective randomized controlled trial: Seok Min Hong, Yeso Choi, Sung Min Park, Jae Yong Byun; Res Vestib Sci. 2024;23(3):95-100. Published online September 15, 2024; DOI: https://doi.org/10.21790/rvs.2024.012

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Abstract PDF: Objectives
This study aimed to compare the efficacy of a combined steroid and diuretic (isosorbide) treatment with that of steroid-only treatment in patients with acute low-tone sensorineural hearing loss (ALHL).
Methods
A total of 34 patients with ALHL were recruited between January 2018 and December 2019 and randomized into two groups: a steroid-with-diuretic (isosorbide) group and a steroid-only group. The steroid-with-diuretic group received oral methylprednisolone for 10 days and isosorbide for 14 days, while the steroid-only group received methylprednisolone for 10 days. Hearing outcomes were measured using pure-tone audiometry at 8 weeks posttreatment. The outcomes were the absolute hearing gain at low frequencies (125, 250, and 500 Hz) and the recovery rate, which was classified into complete, partial, unchanged, progressive, and fluctuating.
Results
Of 34 patients, 30 (15 in each group) were analyzed. No significant differences were observed in baseline characteristics between the groups. The steroid-with-diuretic group showed higher absolute hearing gains at all three low frequencies than the steroid-only group, but the differences were not statistically significant complete recovery was observed in 13 patients in each group, with partial recovery in two patients in the steroid-with-diuretic group and unchanged outcomes in two patients in the steroid-only group. No patient exhibited disease progression.
Conclusions
Although combined steroid and diuretic therapy yielded better hearing outcomes than steroid-only therapy, the differences were not statistically significant. Further studies with larger sample sizes and extended follow-up periods are necessary to confirm these findings.

Does dimenhydrinate delay recovery of vestibular ocular reflex in acute unilateral vestibulopathy? A retrospective comparative study: Minah Shin, Chae-Young Kim, Ji Eun Choi, Jae Yun Jung, Min Young Lee; Res Vestib Sci. 2024;23(3):89-94. Published online September 15, 2024; DOI: https://doi.org/10.21790/rvs.2024.006

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Abstract PDF: Objectives
Acute unilateral vestibulopathy (UVP), also known as vestibular neuritis, is the third most common peripheral vestibulopathy. The acute autonomic symptoms of UVP can be controlled by the H1-receptor antagonist dimenhydrinate. Despite concerns about prolonged recovery from suppressed vestibular compensation when using dimenhydrinate, research is limited. Thus, we investigated the effect of dimenhydrinate on the recovery of UVP patients.
Methods
We retrospectively analyzed patients who were diagnosed with UVP from April 2018 to April 2022. The patients were divided into those who were prescribed dimenhydrinate during admission and those who were not. Recovery from UVP was defined subjectively and objectively. Subjective recovery (SR) had occurred in a patient whose dizziness clearly subsided. Objective recovery (OR) was used when the video head-impulse test (VHIT) or rotary chair test (RCT) no longer indicated vestibular dysfunction.
Results
Dimenhydrinate was prescribed to 15 patients (19.0%) during admission. The dimenhydrinate group had smaller proportions of SR and OR at 3 months after diagnosis of UVP. In terms of VHIT, the non-dimenhydrinate group had a greater increase in gain for the 3 months than the dimenhydrinate group in the semicircular canals when measured by the VHIT. The difference in gain between the two groups was significant at 0.16 Hz during follow-up RCT.
Conclusion
These results suggest that dimenhydrinate should be carefully used in UVP patients as it may have a negative effect on vestibular compensation.

Review Articles

Treatment of hemodynamic orthostatic dizziness/vertigo: Hyun Ah Kim; Res Vestib Sci. 2024;23(3):79-88. Published online September 15, 2024; DOI: https://doi.org/10.21790/rvs.2024.017

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Abstract PDF: Orthostatic dizziness occurs when a person feels dizzy or lightheaded upon standing up. Hemodynamic orthostatic dizziness can result from autonomic dysfunction, such as orthostatic hypotension or postural tachycardia syndrome. The International Classification of Vestibular Disorders has established diagnostic criteria for hemodynamic orthostatic dizziness/vertigo. These criteria help clinicians understand the terminology associated with orthostatic dizziness/vertigo and differentiate it from dizziness caused by global brain hypoperfusion and other etiologies. Effective treatment involves interpreting the results of autonomic function tests, which can lead to improvements in orthostatic dizziness and help prevent falls related to this condition. This paper discusses general management strategies and specific treatments for orthostatic hypotension and postural tachycardia syndrome, highlighting the importance of tailored care based on the most recent clinical insights.

Review on the impact of spaceflight stressors on the vestibular system: beyond microgravity to space radiation: Hui Ho Vanessa Chang, Kyu-Sung Kim; Res Vestib Sci. 2024;23(3):71-78. Published online September 15, 2024; DOI: https://doi.org/10.21790/rvs.2024.013

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Abstract PDF: Understanding the effects of microgravity on the vestibular system has been a primary focus of space research, driven by the need to counteract the often-debilitating impacts of altered gravity environments and maintain operational performance in space. Research using both space-based and ground-based models has identified structural and functional changes in the vestibular system, highlighting its significant capacity for sensorimotor adaptation. As human space exploration progresses towards missions beyond low Earth orbit for extended periods, additional stressors, such as space radiation, may impact the vestibular system. Early studies on space radiation using animal models and insights from radiotherapy have shown that the vestibular system is more vulnerable to radiation than previously understood. This paper provides a brief review of (1) dysfunctions in spatial orientation, gaze stabilization, posture, and locomotion observed in astronauts; (2) ground-based experiments on animals that likely explain these vestibular and sensorimotor dysfunctions; and (3) studies examining the effects of radiation on the vestibular system and its implications for vestibular function in space.

Smartphones versus goggles for video-oculography: current status and future direction: Pouya Barahim Bastani, Shervin Badihian, Vidith Phillips, Hector Rieiro, Jorge Otero-Millan, Nathan Farrell, Max Parker, David Newman-Toker, Ali Saber Tehrani; Res Vestib Sci. 2024;23(3):63-70. Published online September 15, 2024; DOI: https://doi.org/10.21790/rvs.2024.009

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Abstract PDF: Assessment of eye movements is the cornerstone of diagnosing vestibular disorders and differentiating central from peripheral causes of dizziness. Nonetheless, accurate assessment of eye movements is challenging, especially in the emergency department and primary care settings. To overcome this challenge, clinicians objectively measure eye movements using devices like video-oculography (VOG) goggles, which provide a video recording of the eye and quantified eye position traces. However, despite the value of VOG goggles in studying eye movements, barriers such as high prices and the need for dedicated operators have limited their use to subspecialty clinics. Recent advancements in the hardware and software of smartphones have positioned them as potential alternatives to VOG goggles that can reliably record and quantify eye movements. Although currently not as accurate as VOG goggles, smartphones can provide a cheap, widely available tool that can be used in various medical settings and even at home by patients. We review the current state and future directions of the devices that can be used for recording and quantifying eye movements.

Video Report

Aperiodic alternating nystagmus in acute lateral medullary infarction: a video report: Ji-Yun Park; Res Vestib Sci. 2024;23(2):61-62. Published online June 14, 2024; DOI: https://doi.org/10.21790/rvs.2024.010

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PDF Supplementary Material

Original Articles

Effect of early high-dose steroid treatment in patients with acute vestibular neuritis: a retrospective case-control study: Jung-Yup Lee, Hyun-Seok Kang, Sang-Hyun Kim, Min-Beom Kim; Res Vestib Sci. 2024;23(2):53-60. Published online June 14, 2024; DOI: https://doi.org/10.21790/rvs.2024.007

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Abstract PDF: Objectives
This study is performed to evaluate the effect of early steroid treatment within 24 hours of onset in acute vestibular neuritis (AVN).
Methods
We performed a retrospective case-control study with 46 patients with AVN. Video head impulse test paradigm (HIMP) and suppression HIMP were performed, and dizziness handicap index (DHI) was determined at initial; all tests were repeated at 1 month. Patients were divided into two groups depending on whether they were treated with steroids (group S, n=21) or not (group n-S, n=25).
Results
There was no significant difference in age, sex, and side between the two groups. In HIMP, group S showed a significantly lower occurrence of overt corrective saccade (CS) (p=0.034) and lower peak velocity of overt CS (p=0.020) than group n-S at 1 month. In addition, the DHI score at 1 month was significantly lower in group S than in group n-S (p=0.040). In correlation analysis between subjective symptom and objective parameters, the DHI score showed a significant correlation with the occurrence of overt CS (p=0.028) and PR score (p=0.006) at 1 month.
Conclusions
Early steroid treatment in AVN would be helpful for relieving symptoms and the improvement of vestibular ocular reflex function in the recovery phase.

Serum otolin-1 level is specific to benign paroxysmal positional vertigo: Hoon Kim, Eun Ji Kim, Eunjin Kwon, Seong-Hae Jeong; Res Vestib Sci. 2024;23(2):46-52. Published online June 14, 2024; DOI: https://doi.org/10.21790/rvs.2024.008

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Abstract PDF: Objectives
When we see patients with a history of positional vertigo (PV), many patients are diagnosed with benign paroxysmal PV (BPPV) by performing a typical history and nystagmus during a positioning maneuver. Recent studies reported that Otolin-1 can be detected in serum and that its levels significantly increase with age and BPPV. Herein, we tried to study the relationship between serum otolin-1 level and the other clinical aspects in patients with PV.
Methods
We measured the serum levels of otolin-1 in 117 BPPV patients (82 females; age range, 43–92 years; mean age±standard deviation [SD], 68.5±10.5 years), referred to as the BPPV group; and nine patients (seven females; age range, 61–79 years; mean age±SD, 66.9±5.9 years) with PV not compatible with BPPV, referred to as another PV group. All the BPPV patients were treated with an appropriate canal repositioning maneuver followed by blood sampling within 1 week.
Results
The serum levels of otolin-1 were higher in the BPPV group than in another PV group (mean±SD, 350.1±319.1 pg/mL vs. 183.6±134.1 pg/mL, respectively; p=0.037). However, there were no differences in both laboratory findings (serum vitamin D, C-telopeptide of type collagen, and bone mineral density) and clinical findings (age, sex, vertigo duration, ear disease, ear symptom, migraine, motion sickness, trauma, and previous BPPV) between these two groups.
Conclusions
Serum otolin-1 level could help predict the current existence of BPPV in patients with PV. However, further validation studies are needed.

Prevalence and preferred medication for vestibular migraine in Menière’s disease: a multicenter retrospective cohort study in Korea: Dong-Han Lee, Hong Ju Park, Kyu-Sung Kim, Hyun Ji Kim, Jae-Yong Byun, Min-Beom Kim, Minbum Kim, Myung-Whan Suh, Jae-Hyun Seo, Jong Dae Lee, Eun-Ju Jeon, Myung Hoon Yoo, Seok Min Hong, Sung-Kwang Hong, Hyo-Jeong Lee, Jung Woo Lee, Se-Joon Oh, Hyun Ah Kim, Hyung Lee, Eek-Sung Lee, Eun-Jin Kwon, Seong-Hae Jeong, Jeong-Yoon Choi, Chang-Hee Kim; Res Vestib Sci. 2024;23(2):37-45. Published online June 14, 2024; DOI: https://doi.org/10.21790/rvs.2024.005

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Abstract PDF Supplementary Material: Objectives
The aim of this study is to categorize headaches associated with definite Menière’s disease (MD) according to diagnostic criteria, to determine their prevalence, and to investigate the preferred medication across participating centers.
Methods
Patients diagnosed with definite MD at 17 university hospitals in otolaryngology or neurology departments in Korea between January 1, 2021 to December 31, 2021 were retrospectively included. Data on the presence of accompanying vestibular migraine (VM), migraine or non-migraine headaches, and clinical information were collected. A survey was conducted to assess preferences for treatment drugs for vertigo and headache control in MD patients with headache.
Results
A total of 435 definite MD patients were included, with a mean age of 57.0±14.9 years. Among them, 135 (31.0%) had accompanying headaches, of whom 48 (11.0% of all definite MD patients) could be diagnosed with VM. The prevalence of comorbid VM (definite and probable) was significantly higher in females (41 of 288, 14.2%) than in males (7 of 147, 4.8%) (p<0.05). There was no significant difference in the prevalence of comorbid VM between unilateral and bilateral MD patients (10.8% and 13.6%, respectively) (p > 0.05). Benzodiazepines, antihistamines, and antiemetics were mainly preferred for acute vertigo control, while nonsteroidal anti-inflammatory drugs, acetaminophen, and triptans were preferred for acute headache control, and topiramate, propranolol, and calcium channel blockers were mainly preferred for headache prevention.
Conclusions
VM is not uncommon in patients with definite MD in Korea. Further research is needed to understand the differences in headache prevalence and preferred medications across different centers.

Case Reports

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.

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.

Complete ocular tilt reaction with subjective visual vertical tilt in a patient with a medial prefrontal cortex lesion: a case report: Hyung Lee, Hyun Ah Kim; Res Vestib Sci. 2024;23(1):24-27. Published online March 15, 2024; DOI: https://doi.org/10.21790/rvs.2023.136

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Abstract PDF: A 61-year-old male patient undergoing chemotherapy for esophageal cancer presented with symptoms of rightward tilting while both sitting and walking. A neurological examination revealed a head tilt, skew deviation with hypertrophy of the left eye, and a rightward shift in his gait. No spontaneous nystagmus was observed, and the vestibulo-ocular reflex was normal. Magnetic resonance imaging of the head revealed a suspected metastatic lesion in the right medial prefrontal cortex. Following the initiation of levetiracetam treatment, the patient demonstrated marked improvement, with the resolution of both head tilt and skew deviation within 1 month. Traditionally, the ocular tilt reaction has been attributed to unilateral or asymmetric dysfunction of the graviceptive pathways extending from the utricle to the upper midbrain lesions. However, this case highlights the potential involvement of the prefrontal cortex in the ocular tilt reaction. Further research is warranted on the role of the prefrontal cortex within the vestibular system.

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