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Objective: To evaluate semicircular canal function using video head impulse test (vHIT) in relapsing polychondritis (RP) patients presenting with dizziness and sensorineural hearing loss., Study Design: Retrospective case review., Setting: Tertiary referral center., Patients: Three patients with RP underwent vHIT and hearing tests., Intervention: Diagnostic., Main Outcome Measures: The gain in vestibulo-ocular reflex (VOR) and the presence of catch-up saccade were examined, and the correlation between semicircular canal dysfunction and hearing loss was investigated., Results: Of the six ears, five exhibited semicircular canal dysfunction. Among these, one ear showed dysfunction in two semicircular canals, while the remaining four ears demonstrated dysfunction in all three semicircular canals. Sensorineural hearing loss, ranging from moderate to profound, was detected by pure-tone audiometry in all six ears. Furthermore, a significant correlation was observed between VOR gain in the horizontal semicircular canal (HSC) and hearing level., Conclusions: This study demonstrated semicircular canal dysfunction in RP patients presenting with dizziness and hearing loss using vHIT. Moreover, a significant correlation was found between HSC dysfunction and the severity of hearing loss. While inner ear involvement is a key clinical symptom included in the diagnostic criteria for RP, there have been few reports evaluating vestibular dysfunction, and this is the first report on the evaluation of several cases using vHIT. Accurate assessment of vestibular function by vHIT may facilitate early diagnosis and intervention in RP, potentially improving patient outcomes., Competing Interests: Conflicts of interest and source of funding: The authors disclose no conflicts of interest and sources of funding., (Copyright © 2024, Otology & Neurotology, Inc.)

Objective: Persistent postural perceptual dizziness (PPPD) is a clinical condition characterized by unsteadiness present on most days for a period of at least 3 months. The aim of our work was to assess vestibular function, the role of anxiety, and possible interactions between visual and vestibular systems in patients with PPPD., Study Design: Cross-sectional prospective study., Setting: Tertiary referral center., Patients: Twenty-five PPPD patients., Interventions: Clinical history was collected before examination; vestibular function was assessed through bedside examination, video and functional head impulse test (video-HIT, f-HIT). The latter test was based on having the patient identify an optotype displayed on a computer screen during passive head rotations. The test was repeated while optokinetic stimulation (OKS) was given on the screen. Results were compared with those of 25 controls. State and trait anxiety levels were measured with the State-Trait Anxiety Inventory (STAI) questionnaire. Anxiety before and after vestibular examination was assessed using a VAS scale., Main Outcome Measure: Results of video and functional HIT with and without OKS., Results: Video-HIT and f-HIT showed normal values in all subjects. f-HIT with OKS provoked more reading errors in patients than in controls. The interaction of group per time detected different decreasing trends between the two groups (p = 0.0002).Patients presented a reduction in anxiety levels after examination. Nine patients fulfilled diagnostic criteria for vestibular migraine, eight of whom presented nystagmus either to positional tests or vibration test. Only anxiety levels before testing were predictive of worsening of f-HIT with optokinetic stimulation (p = 0.0007)., Conclusions: Our data support the hypothesis that increased anxiety may play a role in visuo-vestibular interactions; moreover, they are not inconsistent with the hypothesis that OKS might provoke a "threatening effect," leading to gaze bias during examination.

Objectives: Dizziness and balance problems are common in the elderly, and benign paroxysmal positional vertigo (BPPV) is one of the most common causes of dizziness. The aim of this study is to investigate the subtype distribution of geriatric BPPV in a single tertiary referral center, and compare the treatment efficacy according to the subtype of BPPV., Study Design: Retrospective study., Setting: Tertiary referral academic center., Patients: The consecutive 316 elderly patients diagnosed with BPPV between March 2013 and March 2019 were included., Main Outcome Measures: Using a head-roll and Dix-Hallpike tests, subtype of BPPV was determined. Once the diagnosis of BPPV was made, patients were treated by its corresponding canalith repositioning maneuver (CRM)., Results: Among 316 elderly patients with BPPV, 143 patients (45%) were diagnosed with posterior semicircular canal BPPV, 46 patients (15%) were diagnosed with lateral semicircular canal (LSCC) canalolithiasis, 126 patients (40%) were diagnosed with LSCC cupulolithiasis, and 1 patient (0%) was diagnosed with anterior semicircular canal BPPV. While 66 and 63% of the patients with posterior semicircular canal BPPV and LSCC canalolithiasis recovered after one session of CRM, only 32% of the patients with LSCC cupulolithiasis recovered after one session of CRM., Conclusion: The proportion of LSCC cupulolithiasis was higher in the elderly, and treatment efficacy by CRM is lower in LSCC cupulolithiasis than other subtypes of BPPV. High prevalence of LSCC cupulolithiasis may be explained by a delay between onset of BPPV and patient's presentation to the tertiary referral hospital or pathophysiology of ageotropic positional nystagmus other than otoconial attachment on the LSCC cupula in the elderly.

Objective: We analyzed the clinical characteristics of quite a large cohort of patients with bilateral posterior canal benign paroxysmal positional vertigo (bil-BPPV) with respect to the rate and types of recurrence., Study Design: Retrospective case review., Setting: Outpatient dizziness clinic., Patients: About 2,050 patients diagnosed with BPPV during the years 2003 to 2018 were reviewed., Results: Sixty (2.9%) were diagnosed with bil-BPPV. Fifty three (88%) were idiopathic and seven (12%) posttraumatic. Multiple BPPV episodes were encountered in 28 (47%) patients. Patients with bil-BPPV and multiple BPPV episodes were comparable with patients with a single attack of bil-BPPV except for older age and longer follow up. The most frequent type of recurrence following a bil-BPPV episode was posterior canal canalolithiasis (37.5%) and bil-BPPV (31.3%). Combined (posterior and horizontal) BPPV was encountered in 12.5% while horizontal canal involvement was found in only 7% of recurrences., Conclusions: The prevalence of bil-BPPV amongst all BPPV patients was lower than previously reported possibly due to stricter selection criteria. Older age and longer follow up of patients with multiple BPPV episodes than those with a single episode of bil-BPPV is in accordance with the theory of degenerative otoconia loosening. In contrast to the general consensus regarding random recurrences of BPPV side and subtypes, bil-BPPV recurred more frequently than expected. This might be the consequence of individual vulnerability to head movements, increased bone metabolism or an underlying vestibular pathology.

Objectives: To compare the efficacy of the home treatment program combined with office-based canalith repositioning procedure (CRP) versus office-based CRP alone for benign paroxysmal positional vertigo (BPPV)., Study Design: Randomized controlled trial., Method: One hundred six patients with BPPV were randomly assigned to the home treatment program combined with office-based CRP group and the office-based CRP only group. The canalith repositioning procedure was performed in all patients at an out-patient clinic. The patients in the home treatment group were additionally instructed to do the exercise tailored for their affected canal at home every day. The presence of nystagmus was recorded. The symptom of vertigo and its impact on daily life were evaluated by the Dizziness Handicap Inventory (DHI) and a visual analog scale (VAS). All outcomes were evaluated at 1, 2, and 4 weeks after the initial treatment. A cure was defined as a patient having no nystagmus on the appointment date., Results: The success rate of the home treatment program combined with office-based CRP group and the office-based CRP only group were 100 and 91.67%, respectively (p = 0.043). The nystagmus duration, latency, DHI, and VAS scores decreased significantly from baseline at 1, 2, and 4 weeks for both groups (p < 0.001). No significant side effects were noted in either of the groups., Conclusion: The office-based CRP plus home treatment program was more effective than the CRP only group for BPPV. Both groups were effective in reducing the symptom of vertigo and its impact on daily life., Trial Registration: Clinicaltrials.in.th/TCTR20160810001.

Objective: To test the degree of vestibular end-organ dysfunction by means of contemporary vestibular testing and examine to which extend these findings correlate to the hearing loss, tumor size, and dizziness handicap registered in vestibular schwannoma patients., Setting: Tertiary referral center., Patients: Eighty-nine patients diagnosed with unilateral vestibular schwannoma., Intervention(s): Patients were evaluated by means of the Dizziness Handicap Inventory (DHI), magnetic resonance imaging scan as well as an extensive audiovestibular test-battery including pure-tone audiometry, ocular vestibular evoked myogenic potentials, cervical vestibular evoked myogenic potentials, and video head impulse test of all six semicircular canals., Main Outcome Measure(s): Patients were divided into four groups according to their number of dysfunctional vestibular end-organs. These groups were subsequently analyzed for differences in DHI score, pure-tone average, and tumor size. The group of patients with zero abnormal vestibular test results was used as index group., Results: For the group with three or more abnormal vestibular test results it was possible to find a statistical significant increase in both DHI score, pure-tone average, and tumor size. This was only found for the latter two parameters in the group with dysfunction of two vestibular end-organs. It was not possible to detect any statistical significant differences in the group with only one dysfunctional end-organ., Conclusions: Substantial loss of vestibular function is correlated to a higher degree of dizziness-induced handicap, hearing loss, and tumor size in vestibular schwannoma patients. Tumor size and audiometry may potentially be used as rough markers of residual vestibular function.

Objective: To present a systematic review of the current data on persistent postural-perceptual dizziness (PPPD), a useful and relatively new diagnosis for a disorder that has previously been known by many different names. In addition, to discuss diagnostic criteria and management strategies for this condition with the otologist in mind., Data Sources: CINAHL, Embase, PubMed, Medline, PsycINFO, PubMed, Google Scholar., Review Method: The phrase "persistent postural-perceptual dizziness" and its acronym "PPPD" were used., Results: From 318 articles, 15 were selected for full analysis with respect to PPPD. Most were case-control studies, with one consensus paper from the Bárány Society available. Overall, the pathophysiology of PPPD remains relatively poorly understood, but is likely to be a maladaptive state to a variety of insults, including vestibular dysfunction and not a structural or psychiatric one. Cognitive behavioral therapy, vestibular rehabilitation, selective serotonin uptake inhibitors (SSRIs), and serotonin-norepinephrine reuptake inhibitors (SNRIs) all seem to have a role in its management., Conclusions: PPPD is useful as a diagnosis for those treating dizziness as it helps to define a conglomeration of symptoms that can seem otherwise vague and allows for more structured management plans in those suffering from it.

Objective: To evaluate the association between Dizziness Handicap Inventory-Screening version (DHI-S) score and spatiotemporal gait parameters using SoleSound, a newly developed, inexpensive, portable footwear-based gait analysis system., Study Design: Cross-sectional., Patients: One hundred eighteen patients recruited from otology clinic., Intervention(s): Subjects completed the DHI-S survey and four uninterrupted walking laps wearing SoleSound instrumented footwear on a hard, flat surface for 100 m., Main Outcome Measure(s): For each subject, mean and coefficient of variation (CV) of stride length, cadence, walking speed, foot-ground clearance, double-support time, swing period, and stance-to-swing were computed by considering 40 strides of steady-state walking within each lap. Linear regression models were employed to study correlations between these variables and DHI-S scores after adjusting for age, sex, and race/ethnicity., Results: Patients with higher DHI-S score took shorter steps and less steps per minute (-0.017 m and -1.1 steps/min per every four-point increase in DHI-S score, p < 0.05) than patients with a lower DHI-S score, with slower walking speed (-0.025 m/s per every four-point increase in DHI-S score, p < 0.01). Additionally, patients with higher DHI-S scores showed larger variability in all analyzed temporal parameters (+0.1% for CV of cadence, +0.5% for CV of double support period, +0.2% for CV of swing period, and +0.4% for CV of stance-to-swing, per every four-point increase in DHI-S score, p < 0.01)., Conclusion: SoleSound was effective in measuring a wide range of gait parameters. Patients' self-perception of vestibular handicap, as assessed with DHI-S, is associated with deterioration in measurable gait parameters independent of age.

Objective: Evaluate the long-term patient-reported outcomes of surgery for superior canal dehiscence syndrome (SCDS)., Study Design: Cross-sectional survey., Setting: Tertiary referral center., Patients: Adults who have undergone surgery for SCDS with at least 1 year since surgery., Main Outcome Measure(s): Primary outcome: change in symptoms that led to surgery., Secondary Outcomes: change in 11 SCDS-associated symptoms, change in psychosocial metrics, and willingness to recommend surgery to friends with SCDS., Results: Ninety-three (43%) respondents completed the survey with mean (SD) time since surgery of 5.3 (3.6) years. Ninety-five percent of respondents reported the symptoms that led them to have surgery were "somewhat better," "much better," or "completely cured." Those with unilateral symptoms were more likely to report improvement than those with bilateral symptoms. There was no difference between those with short (1-5 yr) versus long (5-20 yr) follow-up. Each of the SCDS-associated symptoms showed significant improvement. The largest improvements were for autophony, pulsatile tinnitus, audible bodily sounds, and sensitivity to loud sound. Headaches, imbalance, dizziness, and brain fog showed the least improvements. Most patients reported improvements in quality of life, mood, and ability to function at work and socially. Ninety-five percent of patients would recommend SCDS surgery., Conclusions: Respondents demonstrated durable improvements in the symptoms that led them to have surgery. Auditory symptoms had the greatest improvements. Headaches, imbalance, dizziness, and brain fog showed the least improvements. Nearly, all patients would recommend SCDS surgery to others. These results can be used to counsel patients regarding the lasting benefits of surgery for SCDS.

Objective: We attempted to investigate whether the integrity of saccular function influences the severity of subjective dizziness after vestibular rehabilitation in vestibular neuritis., Study Design: Retrospective analysis., Setting: Tertiary referral center., Patients: Forty-six patients with acute unilateral vestibular neuritis were included., Interventions: Diagnostic, therapeutic, and rehabilitative., Main Outcome Measures: All the patients completed vestibular rehabilitation therapy until their computerized dynamic posturography and rotary chair test results were significantly improved. The rehabilitation patients were classified into the normal to mild subjective dizziness and moderate to severe subjective dizziness groups according to the dizziness handicap inventory score (cutoff of 40). Differences between the two groups were analyzed., Results: After rehabilitation, 32.6% of the patients still complained of moderate to severe dizziness. Age, sex distribution, the presence of comorbidities, caloric weakness, pre- and postrehabilitation gain values in rotary chair test, postrehabilitation composite scores in posturography, and the duration of rehabilitation were not significantly different between the two groups. However, initial dizziness handicap inventory (DHI) score and composite score in dynamic posturography were worse and the proportion of patients with absent cervical vestibular-evoked myogenic potential in the moderate to severe group was much higher (93.3% vs. 35.5%, p < 0.001). After multiple regression analysis of those factors, initial DHI score and absent cervical vestibular-evoked myogenic potential response were identified as being associated with higher postrehabilitation DHI score., Conclusion: Saccular dysfunction in acute vestibular neuritis can contribute to persistent subjective dizziness, even after the objective parameters of vestibular function tests have been improved by vestibular rehabilitation.

Objective: To analyze somatic and psychological factors affecting the outcomes of in-hospital vestibular rehabilitation in patients with intractable dizziness., Materials and Methods: The study involved 138 patients with persistent dizziness caused by peripheral vestibular dysfunction. They were hospitalized and taught to conduct a vestibular rehabilitation program for 30 minutes by themselves three times a day over 5 days. They were then instructed to continue performing the program every day after discharge. Several questionnaires were conducted immediately before, and 1 month after, the treatment. For example, the dizziness handicap inventory (DHI), the somatosensory catastrophizing scale (SSCS), and indexes of depression and anxiety. Posturography was also performed. The main outcome was the difference between the DHI scores before and after rehabilitation. Body sway was objectively evaluated using static posturography., Results: The vestibular rehabilitation significantly improved the DHI score, the SSCS score, depression, and anxiety. Multivariate analysis indicated that the improvement in the DHI score was poorer in patients who showed high SSCS score before intervention. A higher prevalue of the DHI was associated with greater improvements in this perceived handicap after the rehabilitation. Small body sway pre-rehabilitation was related to positive effects on the DHI score in patients with a high prevalue of the DHI., Conclusion: The vestibular rehabilitation contributed to the improvement of perceived handicap due to dizziness, catastrophization of bodily sensation, and emotional distress. Patients who catastrophized their bodily sensations before vestibular rehabilitation saw smaller improvements in perceived handicap due to dizziness.

Objective: To correlate objective measures of vestibular and audiometric function as well as subjective measures of dizziness handicap with the surface area of the superior canal dehiscence (SCD)., Study Design: Retrospective chart review and radiological analysis., Setting: Single tertiary academic referral center., Patients: Preoperative computed tomography imaging, patient survey, audiometric thresholds, and vestibular evoked myogenic potential (VEMP) testing in patients with confirmed SCD., Intervention(s): Image analysis techniques were developed to measure the surface area of each SCD in computed tomography imaging., Main Outcome Measure(s): Preoperative ocular and cervical VEMPs, air and bone conduction thresholds, air-bone gap, dizziness handicap inventory scores, and surface area of the SCD., Results: Fifty-three patients (mean age 52.7 yr) with 84 SCD were analyzed. The median surface area of dehiscence was 1.44 mm (0.068-8.23 mm). Ocular VEMP amplitudes (r = 0.61, p <0.0001), cervical VEMP amplitudes (r = 0.62, p <0.0001), air conduction thresholds at 250 Hz (r = 0.25, p = 0.043), and air-bone gap at 500 Hz (r = 0.27, p = 0.01) positively correlated with increasing size of dehiscence. An inverse relationship between cervical VEMP thresholds (r = -0.56, p < 0.0001) and surface area of the dehiscence was observed. No association between dizziness handicap and surface area was identified., Conclusion: Among patients with confirmed SCD, ocular and cervical VEMP amplitudes, cervical VEMP thresholds, and air conduction thresholds at 250 Hz are significantly correlated with the surface area of the dehiscence.

Hypothesis: As the anterior and posterior semicircular canals are vital to the regulation of gaze stability, particularly during locomotion or vehicular travel, we tested whether the high-velocity vestibulo-ocular reflex (VOR) of the three ipsilesional semicircular canals elicited by the modified Head Impulse Test would correlate with subjective dizziness or vertigo scores after vestibular neuritis (VN)., Background: Recovery after acute VN varies with around half reporting persistent symptoms long after the acute episode. However, an unanswered question is whether chronic symptoms are associated with impairment of the high-velocity VOR of the anterior or posterior canals., Methods: Twenty patients who had experienced an acute episode of VN at least 3 months earlier were included in this study. Participants were assessed with the video head impulse test (vHIT) of all six canals, bithermal caloric irrigation, the Dizziness Handicap Inventory (DHI), and the Vertigo Symptoms Scale short-form (VSS)., Results: Of these 20 patients, 12 thought that they had recovered from the initial episode whereas 8 did not and reported elevated DHI and VSS scores. However, we found no correlation between DHI or VSS scores and the ipsilesional single or combined vHIT gain, vHIT gain asymmetry orcaloric paresis. The high-velocity VOR was not different between patients who thought they had recovered and patients who thought they had not., Conclusion: Our findings suggest that chronic symptoms of dizziness after VN are not associated with the high-velocity VOR of the single or combined ipsilesional horizontal, anterior, or posterior semicircular canals.

Objective: Patients with peripheral vestibular dysfunction because of gravitational receptor asymmetries display signs of cognitive dysfunction and are assumed to have neurobehavioral sequelae. This was tested with pre- and postoperatively quantitative measurements in three cohort groups with superior semicircular canal dehiscence syndrome (SSCDS) symptoms with: 1) superior canal dehiscence (SCD) repaired via a middle cranial fossa craniotomy and canal plugging only; 2) otic capsule defects not visualized with imaging (no-iOCD) repaired with round window reinforcement (RWR) only; or 3) both SCD plugging and subsequent development of no-iOCD followed by RWR., Study Design: Prospective patient series., Setting: Tertiary referral center., Patients: There were 13 adult and 4 pediatric patients with SSCDS who had completion of neuropsychology test batteries pre- and every 3 months postoperatively. Eight patients had no-iOCD and RWR exclusively, 5 had SCD and plugging exclusively, and 4 had both SCD plugging and then development of no-iOCD with RWR. These cohorts included SSCDS with 2 different dehiscence locations., Interventions: Completion of a neuropsychology test battery preoperatively and at 3, 6, 9, and 12 months postoperatively that included: Beck Depression Inventory-II (BDI); Wide Range Intelligence Test (WRIT FSIQ) including average verbal (crystallized intelligence) and visual (fluid intelligence); Wide Range Assessment of Memory and Learning (WRAML), including the four domains of verbal memory, visual memory, attention/concentration, and working memory; and Delis-Kaplan Executive Function System (D-KEFS). The Dizziness Handicap Inventory (DHI) and the Headache Impact Test (HIT-6) were also completed to assess the impact of their disease on activities pre- and postoperatively., Main Outcome Measures: Quantitative and statistical analysis of their cognitive and neurobehavioral function., Results: The pattern of differences between the SCD group and the no-iOCD group from WRAML verbal, visual, and attention test performance indicate different postoperative clinical trajectories. For the WRAML, there was a statistically significant improvement for visual memory and verbal memory for the no-iOCD only and both (SCD and subsequent no-iOCD) groups, but no mean improvement for the SCD only group. By contrast, the no-iOCD group had significantly lower scores on the WRAML attention test preoperatively, but they recovered postoperatively to match the other groups. The preoperative findings and postoperative outcomes did not differ significantly among patient groups on the WRAML working memory test, D-KEFS motor scores, D-KEFS number and letter scores, or Wide Range Intelligence Test scores. There was a significant decrease in the BDI for all groups. The IQ scores were unchanged. There was a statistically significant improvement in the DHI and HIT-6 scores postoperatively in all groups., Conclusions: There was a marked overall improvement in cognitive and neurobehavioral function postoperatively. Variability may result from duration of underlying disease before intervention. The initial decrement or delay in performance improvement measured in several patients may represent brain reorganization. Greater longitudinal data and greater subject numbers are necessary to better understand and optimize cognitive recovery.

Objectives: To assess the variability of normal values for cervical vestibular-evoked myogenic potentials (cVEMP) testing and to provide guidance regarding which parameters should be reported for clinical practice., Study Design: Forty-eight normal subjects with no history of hearing loss or vestibular symptoms underwent cVEMP testing. Measurement parameters were tabulated and compared to other sets of cVEMP normal values in the literature. The literature was reviewed to assess the clinical significance of abnormal cVEMP results. The distributions of threshold and symmetry ratios for normal subjects were compared to the distributions of 90 patients who underwent cVEMP testing., Setting: Tertiary academic center., Results: Upper limits of 42% symmetry ratio and the range of 65 to 95 dB HL for threshold were established for our center.The quartile coefficients of dispersion were much less than 1.0 for all cVEMP parameters in the literature, suggesting that the variability in normal ranges across the literature is small. The distributions for threshold and symmetry ratio were similar between normal and patient groups. There is a lack of information in the literature regarding the impairment of function resulting from various degrees of abnormality of VEMP results., Conclusions: Normal values for cVEMP parameters are statistically consistent in the literature. The clinical significance of abnormal values has not been validated. For clinical purposes, cVEMP "thresholds" should be reported. Reporting of other parameters is optional.

Hypothesis: Patients with primary ciliary dyskinesia (PCD) have absent or reduced otoconial function compared to the normal population., Background: Investigations in zebrafish show that ciliation is important for the development of the otolith organs, but this has never been evaluated in humans. PCD is a congenital defect of ciliary structure. We undertook a pilot study to determine whether patients with PCD have absent or reduced otoconial function compared to the normal population., Methods: Vestibular function testing, including utricular centrifugation (UCF) testing, vestibular evoked myogenic potentials (VEMPs), and electronystagmography, was undertaken in five patients with known PCD. Patients also completed validated questionnaires regarding subjective balance function and symptoms., Results: There were markedly reduced or unobtainable VEMPs bilaterally in three of the five subjects and unilaterally in the remaining two subjects. No subject had a pathological UCF asymmetry, but three subjects showed utricular abnormalities. The vestibulo-ocular reflex (VOR) at 0.25 Hz sinusoidal rotation was normal in all subjects. There were no subjective dizzy symptoms or balance issues., Conclusion: We speculate that the reduced saccular and utricular function in PCD patients observed in this pilot study suggests a relationship between cilia structure and/or motility, and otoconia seeding and/or positioning. Further investigation is warranted.

Objective: Literature investigating otolith reflexes in patients with vestibular migraine (VM) is variable and primarily describes the descending saccular pathway. This research aimed to study ocular vestibular evoked myogenic potential (oVEMP) and cervical vestibular evoked myogenic potential (cVEMP) prevalence and response characteristics in patients with suspected VM and in control patients. The purpose is to assess vulnerabilities within the ascending utricular and descending saccular pathways in the VM population., Study Design: Retrospective study, Setting: Tertiary academic referral center, Patients: 39 adults with VM, 29 control patients, Main Outcome Measure(s): Air conducted oVEMPs and cVEMPs measured with 500 Hz tone burst stimuli, Results: Age of headache onset was most often in childhood or adolescence, with dizziness onset occurring later. The rate of bilaterally absent oVEMPs was significantly higher (28%, p < 0.01) in the VM group compared with the control group (0%). oVEMP amplitude asymmetry ratios were significantly higher for the definite VM (p < 0.01) and probable VM (p = 0.023) groups than the control group. Eleven patients also had history of concussion; they were significantly more likely to demonstrate bilaterally absent oVEMPs (p < 0.01) in comparison to the control patients. When VM patients with a history of concussion were omitted from analysis, differences in oVEMP amplitude asymmetry (p < 0.01) and bilateral oVEMP absence remained significant (p = 0.015). There were no differences in the rate of bilateral cVEMP presence or response parameters between VM and control groups., Conclusion: VEMP presentation differs for some patients diagnosed with VM. The higher rates of abnormal oVEMPs may suggest greater vulnerability within the ascending utricular-ocular pathway in patients with VM.

Objective: To compare subjective and objective findings between patients with true dehiscence versus thin bone over the superior semicircular canal (SSC)., Study Design: Retrospective case series., Setting: Tertiary referral center., Patients: All patients from our institution with true dehiscence or thin bone over the SSC on computed tomography temporal bone (oblique view) from 2007 to 2013., Main Outcome Measures: Subjective test: Dizziness Handicap Inventory (DHI). Objective tests: Infrared video eye recording with varying stimuli (Tulio, Fistula, and Vibration); vestibular evoked myogenic potential (VEMP); electrocochleography; videonystagmography; pure-tone audiometry (i.e., air-bone gap)., Results: Fifty-four patients (64 ears) were reviewed. Thirty-nine patients (47 ears) had true dehiscence of the SSC on temporal bone computed tomography. Fifteen patients (17 ears) had thin bone over the SSC. There was no statistical difference in DHI scores for patients with true dehiscence versus those with thin bone over the SSC. Only cervical VEMP and air-bone gap via pure-tone audiometry revealed a significant difference between the two groups. The remaining vestibular assessments did not demonstrate any difference. No significant correlations were revealed between DHI and objective test findings across and within the two groups., Conclusion: Among the objective tests, cervical VEMP and pure-tone audiometry are the only tools to distinguish between true dehiscence and thin bone over the SSC. DHI does not differentiate between these two groups. Furthermore, no correlation exists between DHI and any objective finding. Further investigation is necessary to develop a validated subjective symptom index of patients with SSC syndrome.

Objective: To assess the utility of the paraclinical tests in patients presenting with clinical diagnosis of cervicogenic dizziness., Study Design: Case controlled., Setting: Otolaryngology clinic of a tertiary referral hospital center., Patients: Twenty-five subjects with cervicogenic dizziness and 25 subjects with benign paroxysmal positional vertigo., Main Outcome Measures: Symptoms description, Dizziness Handicap Inventory-short form (DHI), Trait anxiety score, cervical joint position error, the smooth pursuit neck torsion and cervical torsion tests on videonystagmography, and standing balance test (timed 10-meter walk with head turns)., Results: The results showed differences in reported symptoms, in mean cervical joint position error (p = 0.001), and cervical torsion test (p = 0.001) between the two groups. There was no between-group difference for DHI scores (p = 0.137), trait anxiety scores (p = 0.240), and walking test: time (p = 0.797), steps (p = 0.963). The Youden index is 0.60 for the predictive value of the cervical joint position error, and the smooth pursuit and the cervical torsion tests., Conclusion: This study showed differences in sensorimotor disturbances between the two groups, particularly in the control of head and eye movements and cervical proprioception. Patients with cervicogenic dizziness were more likely to (1) have a sensation of drunkenness and lightheadedness, (2) have pain induced during the physical examination of the upper cervical vertebrae, (3) have an elevated joint position error of 4.5 degrees during the cervical relocation test, and (4) exhibit more than 2 degrees per second nystagmus during the cervical rotation test. The walking test was not able to differentiate the two groups.

Objectives: (1) To determine if head movements in patients with vestibular deficiency differ from those in normal subjects during daily life activities. (2) To assess if these differences can be correlated with patients' perception of dizziness-induced handicap., Study Design: Prospective matched-pairs study, Setting: Tertiary referral center, Patients: Thirty-one vestibular schwannoma patients with documented postoperative unilateral vestibular loss and their age-, gender-, and physical activity level-matched controls with symmetric vestibulo-ocular reflexes., Interventions: Head movements during 10 tasks from daily life were recorded using body-worn movement sensors., Main Outcome Measures: The time to complete the task, the average head velocity and acceleration during each task, and the number of head turns performed were compared between cases and controls. These measures were then correlated with the self-reported Dizziness Handicap Inventory (DHI) scores of the patients., Results: Patients with a unilateral vestibular deficit took significantly longer to perform most daily life activities compared to controls. Their head movements, however, were not always slower. They adopted a different movement strategy, in certain instances less efficient and more disorganized. Dimensions of movement are not all affected equally after a unilateral vestibular loss with evidence of clear clustering of the differences within dimensions across tasks. There was no correlation between the DHI and patients' performance in those tasks., Conclusion: Vestibular loss, even when compensated, affects patients' movements, which can be measured in an ambulatory setting of daily life activities. The differences in movements associated with vestibular loss do not correlate with the degree of self-reported handicap.

Objective: This study examined the effects of symptom reports of dizziness and imbalance on cognitive function in concussed collegiate football players., Design: Retrospective, descriptive., Setting: University athletic medicine facility., Subjects: Twenty-seven collegiate football players were included in the final analysis: 16 with symptoms of dizziness/imbalance resulting from concussion and 11 without dizziness/imbalance resulting from concussion., Main Outcome Measures: Participants completed the Immediate Postconcussion Assessment and Cognitive Testing (ImPACT) at baseline, at 1 to 2 days postconcussion and 5 to 7 days postconcussion. The ImPACT neurocognitive assessment consists of 6 modules, yielding 4 composite scores: verbal memory, visual memory, visual-motor processing speed, and reaction time. In addition, it includes a postconcussion symptom scale total score., Results: Results revealed that participants with reports of dizziness and imbalance had significantly lower scores on the ImPACT composite scores; however, these individuals also had an overall higher symptom inventory. When accounting for the additional postconcussion symptoms, time was the only significant effect., Conclusion: Dizziness and imbalance are common symptoms postconcussion; however, these symptoms did not predict performance on acute ImPACT scores. Further research is needed to understand the mechanisms causing postconcussion symptoms, including symptoms of dizziness and imbalance, and influence on outcomes postconcussion.

Objective: To determine whether the responses of elders compared with younger patients differed significantly on a structured dizziness case history., Study Design: Retrospective case reviews., Setting: Outpatient balance function testing center., Patients: Two-hundred thirty-three adults who underwent vestibular function testing and completed a structured case history. The mean age of the adult group (18-64 yr) was 46.4 years. The mean age of the old adult group (65 yr and older) was 76.2 years., Main Outcome Measure: Patient's self-reported symptoms on a structured case history questionnaire., Results: Younger adults reported significantly more complaints of true vertigo and associated nausea and vomiting compared with older patients. Older patients tended to report symptoms of unsteadiness or falling. Despite the lack of vertiginous symptoms, BPPV was common in older adults., Conclusion: The clinician should be aware of differences in self-report dizziness symptoms in older patients. Older patients who do not have vertigo may be told that their symptoms are normal for their age, when, in fact, they may have an undiagnosed vestibular system impairment.

Objective: The responsiveness (sensitivity to change) of many self-report measures commonly used with individuals who have balance and vestibular dysfunction has not been assessed. The purpose of this study was to determine the responsiveness of 4 self-report measures including the Activities-Specific Balance Confidence (ABC) scale, Dizziness Handicap Inventory (DHI), Falls Efficacy Scale-International (FES-I), and Vestibular Activities and Participation (VAP) scale in people seeking treatment for vertigo, dizziness, and unsteadiness., Study Design: A prospective descriptive study., Patients: Forty-five patients (mean age, 56 yr; range, 18-79 yr) with vertigo, dizziness, and unsteadiness were included., Main Outcome Measures: Participants completed the measures at their initial physician examination and 4 to 6 weeks later. The follow-up visit included a Global Rating of Change Scale (GROC). The change in total scores for each self-report measure from initial visit to follow-up visit were recorded and compared against the GROC. A Spearman correlation was performed to determine the relationship between all 4 self-report measures and the GROC. A receiver operating characteristic (ROC) curve was also used to evaluate responsiveness., Results: Significant correlations were found between the GROC and ABC (ρ = 0.50), DHI (ρ = 0.61), and FES-I (ρ = 0.36) but not the VAP (ρ = 0.27). The ROC curve analysis showed that the area under the curve was significantly greater than 0.5 for the ABC, DHI, and FES-I., Conclusion: The DHI demonstrated the greatest responsiveness, with an optimal cutoff of a change in 3 points related to significant change.

Objectives: To examine whether shaking the head during the DH exam (HSDH) may improve diagnosis of posterior semicircular canal benign paroxysmal positional vertigo (pBPPV) in patients with a negative Dix-Hallpike (DH) examination., Study Design: A prospective cohort clinical study on consecutive patients with dizziness, who were seen by 2 experienced neurotologists. Patients underwent a complete neurotology examination, including positioning testing with roll test and DH. Patients with a negative DH underwent a HSDH. Patients with a positive DH (Group 1) or only with a positive HSDH (Group 2) underwent a particle reposition maneuver (PRM), which was a modification of the Epley maneuver. Variables including sex, age, the duration of symptoms until diagnosis, and the number of visits required until cure were examined in each group., Setting: A tertiary dizziness clinic and in 2 private clinics., Subjects and Methods: All patients diagnosed with pBPPV., Main Outcome Measures: DH test after head shaking and comparison of variables between the 2 study groups., Results: Sixty nine patients were diagnosed with pBPPV (Group 1). Twelve additional patients were negative on DH but were found positive on HSDH (Group 2), improving the diagnostic yield by 14.8%. There was no statistical relation between the 2 groups and the variables examined; however, there was a trend for longer duration of symptoms (44.3 versus 64 d) and less visits until cure (1.5 versus 1.7 visits) in Group 2., Conclusion: Patients with a negative DH should undergo a HSDH. Patients only diagnosed as pBPPV by a positive HSDH may represent a subgroup with a milder form of disease.

Hypothesis: The purpose of this research is to establish the test-retest reliability and convergent validity of the Falls Efficacy Scale-International (FES-I) in people with vestibular disorders., Background: Individuals with vestibular dysfunction have an increased risk of falling. The FES-I is a measure used to quantify an individual's concern of falling during different tasks., Methods: A cross-sectional descriptive study was used to determine the test-retest reliability and convergent validity of the FES-I. Fifty-three individuals with vestibular or balance dysfunction completed the FES-I twice during an initial evaluation by a neurotologist. Test-retest reliability was assessed using the intraclass correlation coefficient. The convergent validity was measured by correlating the FES-I with the Activities-Specific Balance Confidence (ABC) scale, Dizziness Handicap Inventory (DHI), Vestibular Activities and Participation (VAP) scale, 4-item Dynamic Gait Index (DGI-4), and measuring gait speed., Results: The FES-I demonstrated high test-retest reliability (intraclass correlation coefficient, model 3,1: 0.94; 95% confidence interval, 0.90-0.97) and had concurrent validity with other self-report and physical performance measures (correlation coefficients for the ABC, -0.84; DHI, 0.75; VAP, 0.78; gait speed, -0.55; and DGI-4, -0.55)., Conclusion: The FES-I is a reliable and valid tool for measuring an individual's concern of falling in a sample of people with vestibular disorders.

Objective: Vestibular symptoms are seen variably in patients with otosclerosis, both in patients with the disease and in patients after treatment with stapes surgery. The goal of this study was to objectify any changes of the bone-conducted (BC) ocular vestibular evoked myogenic potentials (oVEMPs) in patients with otosclerosis before and after stapes surgery., Study Design: Twenty-six healthy subjects and 27 patients with otosclerosis were tested in a tertiary care center, and 11 of the patients were tested preoperatively and postoperatively. The ears of patients were divided in 4 groups: normal ears, otosclerotic ears, ears after primary stapes surgery, and ears after revision surgery. The stimulus used in oVEMP testing was a BC stimulus delivered by a mini-shaker at stimulus frequencies of 250 and 500 Hz. oVEMP characteristics were the n1 and p1 latencies, n1 - p1 amplitude, and threshold., Results: No significant differences were seen in all oVEMP characteristics between the 4 groups of ears without surgery nor in the ears that were tested preoperatively and postoperatively., Conclusion: No or undetectably little damage to the utricle is caused by both otosclerotic disease and stapes surgery. There is no additive value of screening with BC oVEMPs perioperatively in otosclerotic patients.

Objective: The round window membrane (RWM) approach is designed to provide an atraumatic approach to scala tympani implantation with the goal of enhanced preservation of hearing and vestibular receptor function. Perimodiolar electrode designs offer advantages in electrophysiologic testing. However, perimodiolar arrays have only been investigated in insertion trials using temporal bone material. The aim of the present study was to evaluate perimodiolar electrode placement in a clinical trial., Materials and Methods: The prospective nonrandomized study included 27 patients (October 2010 to February 2011). Due to the RWM approach, cochlear implantation electrode insertion was performed using a perimodiolar electrode array fitted with a stylet that enables movement through the first cochlear turn by withdrawing the stylet. We judged the feasibility of RWM approaches with perimodiolar electrodes and the electrode placement using flat panel detector radiography. Hearing preservation, vestibular receptor function (vestibular evoked myogenic potentials, subjective haptic vertical, and caloric irrigation), and subjective vertigo were evaluated in all RWM approaches., Results: For anatomic reasons, RWM insertions were possible in 21 cases (78%). The basilar membrane disruption rate was 19% in RWM insertions using perimodiolar electrodes. In those patients with the electrode position within the scala tympani, vestibular receptor functions and subjective vertigo remained unchanged. The residual hearing preservation was unsatisfactory. The mean pure-tone average loss was 21 dB., Conclusion: We believe that if performed regularly, the RWM insertion technique has almost no negative effects on vestibular receptor function and produces no vertigo. However, cochlear hair cells may be more sensitive to electrode insertion traumas than vestibular receptor cells. The use of perimodiolar electrodes may require more atraumatic electrodes to achieve hearing preservation.

Objective: To evaluate the change in self-reported dizziness handicap after surgical repair using the cartilage cap occlusion technique in cases of superior canal dehiscence (SCD)., Study Design: Repeated measures, retrospective chart review., Setting: Tertiary referral center., Patients: Twenty patients over a 2-year period who underwent surgical repair of SCD using the cartilage cap occlusion technique., Intervention: Therapeutic., Main Outcome Measure: Preoperative and postoperative Dizziness Handicap Inventory (DHI) questionnaires were completed (median, interquartile range)., Results: Preoperative (48, 28-56) and postoperative (33, 19-50) total scores were not significantly different. Scores for patients with moderate/severe preoperative DHI scores (DHI, >30; n = 14) demonstrated significant change (p = 0.001, Wilcoxon paired sample test), whereas those with mild scores did not (DHI, ≤ 30; n = 6; p = 0.67)., Conclusion: Change in DHI score is variable. As described by DHI score, patients with higher preoperative handicap may demonstrate significant improvement after surgery, whereas those with mild handicap may not. These results are similar to previous reports and indicate that the cartilage cap occlusion technique may provide an alternative to middle fossa craniotomy approach for surgical management of symptomatic SCD.

Objective: Determine the change in vestibular function in patients receiving a unilateral cochlear implant, and to compare these results with other signs and symptoms., Study Design: Prospective cohort study., Setting: Academic tertiary referral center., Patients: Forty-four adults (mean age, 55 yr; range, 30-76 yr) receiving their first cochlear implant., Intervention: Cochlear implantation., Main Outcome Measures: Horizontal high-frequency vestibulo-ocular reflex (VOR) was measured using the motorized head impulse rotator preoperatively and twice (on average two and 19 months) postoperatively. VOR gain and asymmetry were calculated (mean ± standard deviation). Symptoms were assessed with a structured questionnaire., Results: Gain on the operated side was 0.77 ± 0.26 preoperatively, 0.75 ± 0.30 in the early and 0.73 ± 0.33 in the late postoperative control, and did not change significantly. Mean asymmetry remained within 9% to 10% in all test occasions. Dizziness symptom score or dizziness-related quality of life score did not change significantly. General quality-of-life score improved significantly from that of preoperative 3.5 ± 1.2 to that of 2.6 ± 1.1 postoperatively (p = 0.01). Subjective hearing scores improved significantly from 4.9 ± 0.3 to 2.4 ± 1.0, respectively (p = 0.0000). Gain was decreased significantly in 4 patients (10%) in the early and in 2 patients (7%) in the late postoperative control., Conclusion: Late high-frequency loss of vestibular function or vestibular symptoms is rare but possible after cochlear implantation surgery. This should be taken into account in patient counseling especially when considering bilateral cochlear implant surgery.

Objective: The present investigation was conducted in an effort to assess the level of congruence between patients and spouses for the patient's self-reported vertigo severity and dizziness handicap., Study Design: Prospective study., Patients: Fifty consecutive patients, and their spouses, evaluated in our Balance Disorders Laboratory in the Division of Vestibular Sciences., Main Outcome Measures: Dizziness Handicap Inventory (DHI), Spouse version of the DHI (DHI-SP), Vertigo Symptom Scale (VSS), Spouse version of the VSS (VSS-SP), and the Hospital Anxiety and Depression Scale (HADS)., Results: The mean DHI and DHI-SP total scores were not statistically different from one another (t49 = 1.58, p = 0.16) and were strongly correlated (r = 0.79, p < 0.01). The VSS and VSS-SP scores were statistically different (t49 = 2.33, p = 0.02) but were still moderately correlated (r = 0.56, p < 0.01). Spouses tended to overestimate vertigo severity. We observed an increase in the frequency of occurrence of clinically significant anxiety and depression not only in patients but in spouses as well. Furthermore, anxious patients tended to be married to anxious spouses, and depressed patients tended to be married to depressed spouses. Finally, the mean DHI scores were significantly greater for patients with clinically significant anxiety and/or depression, but the presence of patient anxiety and/or depression did not affect spousal congruence., Conclusion: The results attest to the congruence of patient and spouse perceptions of vertigo severity and dizziness handicap.

Hypothesis: The goal of this study was to assess the impact of dizziness handicap, illness intrusiveness (in relation to vertigo, tinnitus, and hearing problems), and illness uncertainty on depression in people with the symptoms of Ménière's disease., Background: Ménière's disease is a progressive disease of the inner ear, the symptoms of which are vertigo, tinnitus, hearing loss, and aural fullness. Although pharmacologic treatments may reduce acute vertigo spells and dizziness, they rarely disappear entirely. Previous research shows that Ménière's disease is unpredictable and has a negative impact on patients' quality of life., Methods: Questionnaires measuring Dizziness Handicap, Illness Intrusiveness, Illness Uncertainty, and Depression were completed by 74 people with self-reported symptoms of Ménière's disease. Bivariate correlations, repeated-measures analysis of variance, and multiple regression analyses were used to assess the contribution of dizziness handicap, illness intrusiveness, and illness uncertainty to depression., Conclusion: Vertigo was more intrusive than tinnitus, hearing problems, and most other comparator illnesses. The intrusiveness of the symptoms of Ménière's disease accounted for 32% of the variance in depression scores, which were high; illness uncertainty did not account for additional variance. Dizziness handicap accounted for 31% of the variation in depression. Although the symptoms of Ménière's disease may not be alleviated by psychological methods, programs that target cognitions in relation to the embarrassment in front of others, and the feeling of being handicapped, may lessen the psychosocial impact of the symptoms of Ménière's disease, which may reduce some of the depression felt in this group.

Objective: The objective of this study was to examine whether any clinical difference existed with respect to the characteristics of dizziness in vestibular neuritis (VN) and sudden sensorineural hearing loss with vertigo (SHLV)., Study Design: Retrospective review., Setting: Tertiary referral center., Patients: Included in this study were 22 SHLV patients and 32 VN patients who had been confirmed of unilateral caloric weakness. Sudden sensorineural hearing loss accompanied sudden attack of rotatory vertigo., Main Outcome Measures: Clinical features such as comorbidity, duration of vertigo, duration of spontaneous nystagmus, and others were compared between the 2 groups. Medical records related to the vestibular function test were also reviewed., Results: When comparing comorbid diseases and symptoms, there was no significant difference between the 2 groups. There were also no differences in the duration of spontaneous nystagmus and vertigo symptoms. However, the proportion of patients with abnormal vestibular evoked myogenic potential response was significantly smaller in the VN group compared with the SHLV group., Conclusion: Patients with SHLV are much more likely to have saccule/inferior vestibular nerve involvement than patients with VN.

Objective: Despite complaints of dizziness, some patients with unilateral compensated vestibular weakness show normal results on Sensory Organization Test (SOT), which is being widely used for the evaluation of vestibular function compensation. The head shake-sensory organization test (HS-SOT) has been suggested to increase the sensitivity of SOT. In HS-SOT, the patient is required to shake head under Conditions 2 and 5 of traditional SOT. However, the sensitivity of HS-SOT remains unelucidated in patients with vestibular neuritis. The aim of this study was to determine the sensitivity of HS-SOT and SOT and compare them with the Dizziness Handicap Inventory (DHI) in detecting balance problems in patients with vestibular neuritis complaining of dizziness., Setting: Tertiary referral center., Patients: A prospective analysis was conducted on all vestibular neuritis patients between September 2009 and April 2011. Thirty-two patients with uncompensated vestibular neuritis were enrolled in this study. Patients with acute symptoms of dizziness, orthopedic problems, or any other severe underlying conditions were excluded., Main Outcome Measures: Equilibrium and vestibular scores of SOT and equilibrium score ratios of HS-SOT and DHI were obtained from each patient after 1 week and 1, 2, and 6 months of the first attack of vestibular neuritis., Results: HS-SOT is more correlated with the DHI than SOT by periods. One month after vestibular neuritis, the correlation between DHI and SOT, HS-SOT Conditions 2 and 5 were -0.301, -0.385, and -0.625, respectively. Six months after vestibular neuritis, the correlation between DHI and SOT, and HS-SOT Conditions 2 and 5 were -0.053, -0.337, and -0.394, respectively., Conclusion: HS-SOT was more sensitive than SOT during the compensation of vestibular neuritis. Specifically, during the compensation of vestibular neuritis, HS-SOT Condition 5 was more correlated with DHI than HS-SOT Condition 2. The results suggest that HS-SOT provides more useful measures for the evaluation of vestibular compensation in vestibular neuritis.

Objectives: To define clinical and laboratory characteristics of bilateral vestibulopathy (BV) and to propose diagnostic criteria of this disorder based on clinical and laboratory findings., Study Design: Retrospective case series review., Materials and Methods: We recruited 108 patients with a clinical suspicion of BV based on presenting symptoms (unsteadiness or oscillopsia during locomotion) and bedside (dynamic visual acuity or head impulse tests) and laboratory (bithermal caloric or rotatory chair tests) findings after excluding the patients with other disorders that may explain the symptoms. Definite diagnosis of BV was made when the patients showed abnormal findings on both bedside and laboratory tests in addition to the symptoms, whereas probable diagnosis was obtained when either the bedside or laboratory findings were abnormal along with the symptoms., Results: All patients had unsteadiness, and 36 (33%) reported oscillopsia. Diminished vestibulo-ocular responses to head impulse in both horizontal directions were present in 45 of the 100 patients evaluated. Dynamic visual acuity was impaired in 65 (95%) of the 68 patients who underwent testing. Fifty-one (57%) patients showed bilateral hyporesponsiveness during bithermal caloric tests. Forty-eight (53%) patients had reduced gain of the vestibulo-ocular reflex during rotatory chair test. By adopting our diagnostic criteria, 93 patients (86%) were diagnosed as having BV, definite in 49 (45%), and probable in 44 (41%)., Conclusion: The proposed diagnostic criteria encompass the symptoms and findings of both bedside and laboratory evaluations and may provide a valuable tool for investigating BV.

Objective: To elucidate the usefulness of clinical orthostatic blood pressure testing (COBP) as a screening tool for autonomic dysfunction., Study Design: In this retrospective case review, the records of 156 consecutive patients with nonotologic dizziness as the primary complaint seen in an academic neurotology clinic between 2005 and 2009 were reviewed. The objective of this study was accomplished by comparing the diagnostic yield of COBP with that of head-upright tilt table testing (HUT) and assessing the sensitivity and specificity of COBP in predicting an abnormal HUT in patients with nonotologic dizziness., Setting: Ambulatory tertiary referral center., Patients: Patients presenting to the clinic with dizziness without otologic cause., Intervention(s): Clinical evaluation, orthostatic blood pressure testing, and HUT., Main Outcome Measure(s): The primary outcome assessed in this study was patient blood pressure. Blood pressures were measured in the clinic in the following order: supine, sitting, and standing. Positive COBP was defined as a reduction in systolic or diastolic blood pressure greater than 20 or 10 mm Hg, respectively, or both, within 3 minutes of sitting from supine or standing from sitting. For comparison, HUT was used as the gold standard. A positive HUT was defined as a reduction in systolic or diastolic blood pressure greater than 20 or 10 mm Hg, respectively, or both, relative to baseline at any point after initiation of HUT., Results: Forty patients were referred for HUT. Twenty-four (61.5%) of these patients were deemed to have a positive response. Thirty-three patients (85%) referred to HUT were initially evaluated with COBP, which revealed orthostatic hypotension (OH) in 8 patients (24%). COBP was calculated to have sensitivity and specificity of 21% and 71%, respectively, when asymptomatic OH was included in the positivity criteria. When asymptomatic OH was excluded from the positivity criteria, the sensitivity and specificity remained similar at 25% and 76%, respectively. However, the exclusion of asymptomatic OH from the positivity criteria resulted in a decrease in the positive predictive value from 50% to 25% and an increase in the negative predictive value from 40% to 76%. Overall, HUT detected 16 patients with an abnormal result that were missed by COBP testing., Conclusion: Evaluation for autonomic dysfunction should be part of the comprehensive evaluation of a dizzy patient, involving, at a minimum, orthostatic testing of blood pressure and heart rate. Patients with nonotologic dizziness and light-headedness with a normal neurotologic evaluation can reasonably be referred for HUT, even in the presence of normal in-office orthostatic testing.

Objective: To validate the role of vibration-induced nystagmus (VIN) detecting vestibular asymmetry by comparing several vestibulo-ocular reflex (VOR) parameters in the yaw plane., Study Design: Prospective validation study for diagnostic test., Setting: Tertiary referral center., Patients: Seventy-four patients with unilateral vestibular loss of acute onset without a history of fluctuating vestibular function and 24 healthy volunteers., Intervention: Spontaneous nystagmus, head-shaking nystagmus (HSN), and VIN using a 100 Hz handheld vibrator were recorded using a videonystagmography system. Canal paresis on the caloric test and the time constant (TC) on the step velocity test were examined as parameters of the laboratory test., Main Outcome Measures: Correlation analysis between horizontal VOR parameters was performed. Receiver operating characteristic (ROC) curves of these parameters were plotted, and the area under the ROC curve (AUC) was compared according to the lower limiting value of TC on step velocity test as well as the presence of unilateral vestibular loss., Results: VIN was observed in 64 (86%) of 74 patients, and it was directed toward the contralesional side in 98%. VIN showed a significant positive correlation with the canal paresis (r=0.416, p<0.001) and a negative correlation with the TC (r=-0.351, p<0.005). ROC curves of several VOR parameters were compared according to the presence of unilateral vestibular loss. The AUC of VIN was 0.882, and the cutoff intensity of VIN was 2.5 degrees per second. The AUCs of the HSN and spontaneous nystagmus were 0.774 and 0.661, respectively., Conclusion: The lateralization value of VIN was comparable with caloric test and superior to HSN. VIN is a useful vestibular test detecting vestibular asymmetry in the evaluation of dizziness., (© 2011, Otology & Neurotology, Inc.)

Objective: To evaluate the neurotologic findings in patient suffering from migraine with and without vestibular symptoms., Study Design: Comparative cross-sectional and observational study., Setting: Tertiary referral center., Background: Migraine headache is often associated with other symptoms, including dizziness, head motion intolerance, or rotational-type vertigo. The neuro-otologic examination in migrainous patients often gives unremarkable results. To date, it is not fully understood why some migraine patients complain of vestibular symptoms and some do not, and it is not yet clear whether neuro-otologic abnormalities among migraine patients are more common in patients complaining of vestibular symptoms or whether they can be considered a hallmark of migraine itself., Materials and Methods: Forty-four migrainous patients were divided into 2 groups regarding the presence (22 patients, Group 1) or absence (22 patients, Group 2) of vestibular symptoms, and the results were compared with those obtained from a control group (22 normal subjects). All the patients underwent a complete neurotologic study to verify the presence of vestibular abnormalities., Results: : Neurotologic abnormalities were observed in only 34% of the total, and the incidence was very similar in the 2 groups (36.3 versus 31.8%). Central vestibular involvement was observed in 18% of Group 1 and in 18% of Group 2 patients. Peripheral vestibular involvement was demonstrated in 18% of Group 1 patients and in 16% of Group 2 patients., Conclusion: Our data seem to confirm that migraine itself can affect vestibular pathways even if patients do not complain of vestibular symptoms. Vestibular examination alone does not provide enough information for a diagnosis of migrainous vertigo. A careful clinical history is fundamental for assessing the profile of patients with migrainous vertigo.

Objective: To investigate the vestibular evoked myogenic potentials (VEMPs) resulting in benign paroxysmal positional vertigo (BPPV) patients and to verify its clinical applications in BPPV., Study Design: A prospective study., Setting: Tertiary referral dizziness center., Patients: Forty-one patients with diagnosis of BPPV and 92 healthy volunteers who underwent VEMP testing., Intervention: Patients were treated by canalith repositioning maneuvers according to the affected canal, and testing of VEMP was performed at diagnosis and after treatment., Main Outcome Measures: Testing of VEMP was performed in BPPV patients and in the control group. The number of times the canalith repositioning maneuver was repeated until the patient's report of relief from vertigo and findings of negative positioning test were recorded to find out the relationship between VEMP results and the progress of disease., Results: Vestibular evoked myogenic potential results of BPPV patients showed prolonged p13 and n23 latencies compared with those of the control group, and we could not find any significant difference in VEMP latencies between patients with posterior and horizontal canal type of BPPV. The number of times that the maneuver was repeated did not correlate with the degree of latency prolongation, but in the "no response" group, the number of times was considerably greater than that in the "response" group., Conclusion: We found that VEMP latencies are increased in BPPV patients, which may signify neuronal degenerative changes in the macula of the saccule. When an extensive neuronal damage was suspected by VEMP results such as "no response" in VEMP, the disease progress showed a chronic and resistive course. Therefore, we propose that VEMP could be a useful method to determine a clinical prognosis of patients with BPPV.

Objective: To analyze if patients whose vestibular symptoms are associated with nonorganic sway patterns show more evidence of somatization and/or malingering than patients whose vestibular symptoms are associated with normal or physiologically abnormal sway patterns observed in people with documented vestibular pathologic findings., Patients: One hundred fifteen patients with complaints of vestibular dysfunction and hearing impairment., Interventions: Computerized dynamic posturography (CDP) and completion of the Modified Somatic Perception Questionnaire (MSPQ)--a validated test for the detection of malingering., Main Outcome Measures: Computerized dynamic posturography results classified into 4 categories (normal, physiologic abnormal, borderline-aphysiologic, and aphysiologic) were correlated with the results of the MSPQ., Results: A significant CDP group effect on the MSPQ, with the aphysiologic patients scoring significantly higher than the other groups. Moreover, a significantly higher proportion of aphysiologic patients scored more than the MSPQ cutoffs for malingering., Conclusion: Results indicate that patients who have aphysiologic CDP sway patterns are more likely to have higher MSPQ scores. Both aphysiologic CDP results and high MSPQ scores have been associated with intentional exaggeration. These results indicate that patients with both aphysiologic CDP findings and high MSPQ scores are more likely to be intentionally exaggerating their balance-related complaints and deficits.

Objective: To determine the incidence of caloric and rotational chair testing (ROT) abnormalities in a group of patients with chronic suppurative otitis media (CSOM) and to correlate caloric test results with ROT., Patients: Twenty-five patients with CSOM with or without cholesteatoma who were to undergo tympanomastoid surgery., Interventions: Caloric and ROT., Main Outcome Measures: History of dizziness. Vestibular test abnormalities defined by caloric weakness (CW), reduced gain, abnormal phase, or asymmetry on ROT., Results: Among the 25 patients, 13 had bilateral CSOM-most with long-standing disease and history of previous surgical intervention. Of the 25 patients, 19 (76%) demonstrated either unilateral or bilateral CW. Eighteen (72%) demonstrated abnormalities on ROT. Eleven patients (44%) had complaints of vertigo/dizziness, although 2 of these patients had both normal caloric testing and ROT. Unilateral or bilateral CW was 80% accurate in predicting an ROT abnormality, whereas the symptom of vertigo/dizziness was only 48% accurate in predicting an ROT abnormality., Conclusion: The incidence of CW among CSOM patients in this study was high and correlated well with abnormalities on ROT. Interestingly, ROT results correlated better with CW than symptoms of dizziness/vertigo. Although CW findings can be the result of technical limitations in testing patients with CSOM, ROT corroboration of these results suggest that they are valid findings.

Objective: Persistent vertigo and imbalance can occur after surgery for vertigo regardless of surgical approach. This study explored for factors affecting outcome of vertigo surgery., Study Design: Patient survey and chart review., Setting: Tertiary referral neurotologic private practice., Patients/intervention: Of 111 patients (57.7% female; mean age, 52.3 yr), 59 underwent vestibular nerve section (middle fossa, retrolabyrinthine, and translabyrinthine), 25 underwent transmastoid labyrinthectomy, and 27 underwent endolymphatic sac shunt. Eighty-three percent had Ménière's disease. Mean follow-up was 4.3 years., Main Outcome Measures: Primary outcomes included American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) vertigo score and class, number of spells per month, current and change in AAO-HNS disability rating, vertigo and imbalance severity ratings, and frequency of imbalance., Results: Three preoperative factors were consistently related to outcome: AAO-HNS disability rating, imbalance frequency rating, and duration of first symptom ([rho] = 0.19-0.51; all p's < 0.05). Greater disability and more frequent imbalance related to poorer outcome, but longer duration of disease related to better outcome. Presurgery vertigo characteristics were generally not related to outcome. Ménière's patients were more likely to have improvement in imbalance, as were those with no other significant disease and no allergy. The presence of tinnitus in the contralateral ear was associated with poorer outcomes, including a lower rate of results of Classes A and B (p = 0.023). Vertigo as a first symptom and the presence of eye disease also showed relationships to poorer outcome., Conclusion: Those rating themselves as more disabled before surgery are less likely to achieve the best outcomes, whereas frequency and severity of preoperative vertigo are not predictive. Several possible prognostic factors were identified that warrant future prospective study.

Objective: To identify otologic and audiologic characteristics of superior (and posterior) semicircular canal dehiscence (SCD)., Study Design: Retrospective case review., Setting: Tertiary referral center., Patients: Sixty-five adult patients were evaluated for SCD; 26 of 65 (35 ears) had dehiscence., Intervention(s): Otologic examination, high-resolution computerized tomography (CT), air and bone audiometry, tympanometry, acoustic reflex, and vestibular evoked myogenic potential (VEMP)., Main Outcome Measure(s): Imaging demonstrating canal dehiscence, preferentially including Poschel and Stenvers reconstructions. Audiologic findings of pseudoconductive loss, intact ipsilateral stapedial reflex, and abnormally low VEMP thresholds., Results: The most common presenting complaints were autophony of voice and a "blocked ear" (94%), mimicking patulous eustachian tube, including relief with Valsalva or supine position (50%), but without autophony of nasal breathing. Pseudoconductive loss was found in 86% of dehiscence ears, and 60% (21 of 35) of these ears had better than 0-dB-hearing-loss bone conduction thresholds at 250 and/or 500 Hz. Acoustic reflex was present in 89%. Assuming CT as the criterion standard, VEMP resulted in 91.4% sensitivity and 95.8% specificity. One false-positive CT, with abnormal VEMP, resulted in surgical explorations negative for superior SCD but positive for posterior SCD., Conclusion: Semicircular canal dehiscence may present with various symptoms such as autophony, ear blockage, and dizziness/vertigo. A combination of high-resolution CT and audiologic testing is recommended for diagnosis. Low-frequency conductive loss with better than 0 dB hearing level (HL) bone conduction threshold and normal tympanometry, with intact acoustic reflexes, are audiologic signs of SCD. Vestibular evoked myogenic potential is highly sensitive and specific for SCD, possibly better than CT.

Objective: The purpose of this study was to investigate whether Dizziness Handicap Inventory (DHI) score is related to postural performance as assessed by dynamic posturography., Study Design: Retrospective study., Setting: Outpatient in a tertiary referral center., Patients: Ninety-two complete unilateral vestibular loss patients, categorized into 3 groups according to the postlesion stage: 1 to 2 months (n = 32; age, 47.6 +/- 10.7 yr), 4 to 7 months (n= 23; 47.1 +/- 8.37 yr), and 1 year and older (n = 37; 49.2 +/- 9.5 yr)., Main Outcome Measures: Dizziness Handicap Inventory and dynamic balance measured with a seesaw platform moving either in the anterior-posterior or in the mediolateral direction., Results: The mean DHI score was 25.8 +/- 18.7 and the range was 0 to 68. Dizziness Handicap Inventory scores did not differ significantly between the different unilateral vestibular loss groups studied. No difference was detected between the groups for the 3 subscores (emotional, functional, and physical), except that the older-than-1-year group had a significantly higher physical score than the 2 others. No correlation was found between DHI scores and postural indicators for either direction of the platform. However, patients unable to maintain balance when the seesaw platform moved in the mediolateral direction had significantly higher DHI scores than those who did not fall., Conclusion: Even if they are not directly related, we suggest that DHI and dynamic posturography are complementary approaches for appreciating the vestibular compensation process and are thus useful for postoperative counseling for vestibular loss patients.

Objective: The goals of this study were to validate the clinical diagnosis of autonomic dizziness as a cause of chronic nonvertiginous dizziness that may be exacerbated by physical exertion or orthostatic challenges, estimate its prevalence in a tertiary referral population, and investigate the usefulness of three autonomic challenges as objective tests for this condition., Study Design: Laboratory investigation of autonomic activity., Setting: Tertiary care balance center., Patients: Fifteen men and women with symptoms indicative of autonomic dizziness. Subjects with other causes of dizziness, histories of syncope, or psychiatric disorders were excluded., Interventions: Autonomic tests included 45 minutes of head upright tilt (HUT), 20 minutes of 5% CO2 inhalation and then HUT, and 2 minutes of voluntary hyperventilation and then HUT., Main Outcome Measures: Patterns of cardiovascular and respiratory responses and subjective ratings of dizziness, autonomic symptoms, and anxiety during autonomic challenges., Results: Twelve subjects had evidence of autonomic dysfunction, including 10 with abnormal heart rate, blood pressure, or respiratory responses to HUT. Two other subjects had prolonged hypocarbia after voluntary hyperventilation. Many of these abnormalities would have been missed by current autonomic testing paradigms. In one subject, CO2 inhalation revealed latent anxiety. In two subjects, the presence of high symptom ratings without objective autonomic dysfunction prompted a successful search for other diagnoses., Conclusion: Study results validated the clinical syndrome of autonomic dizziness. Autonomic testing protocols may have to be updated to detect clinically relevant abnormalities in patients with dizziness.

Objective: The aim of this study was to assess the incidence of balance problems after acoustic neuroma surgery, evaluating whether disequilibrium is disabling., Study Design: Retrospective observational study., Setting: Rehabilitation center., Patients: A group of 386 patients who underwent acoustic neuroma surgery., Interventions: Patients were selected from a population of 459 subjects who had undergone surgery for acoustic neuroma., Mean Outcome Measures: The Dizziness Handicap Inventory, The Activities-specific Balance Confidence Scale (ABC), and a specific questionnaire on oscillopsia., Results: The specific questionnaire emphasized that 39 patients (10.10%) perceived disequilibrium as disabling, and the oscillopsia handicap score result was moderate in 73.32% of the sample, mild in 21.50%, and severe in 5.18% of patients. The Dizziness Handicap Inventory and ABC scales revealed the presence of handicap and disability due to disequilibrium and the influence of some variables such as sex and a higher oscillopsia handicap score. Dizziness Handicap Inventory and ABC scores were higher in symptomatic patients., Conclusion: Disequilibrium influences handicap and disability after acoustic neuroma surgery. This symptom is also present after several years since surgery, and some patients perceived disequilibrium as disabling.

Objectives: Subjective visual horizontal (SVH) and subjective visual vertical (SVV) used to assess otolith dysfunction and ipsilesional deviation of SVV and SVH in unilateral vestibular dysfunction is well known. The goal of this study was to investigate the clinical use of SVH/SVV and a dizziness scale in the clinical setting of acute unilateral vestibular neuritis., Methods: Thirty-five patients with unilateral vestibular neuritis were investigated. Every patient was diagnosed by physical examination and electronystagmography. Subjective visual horizontal and SVV were assessed during the acute or subacute period; the Dizziness Handicap Inventory (DHI) and Vestibular Disorder Activities of Daily Living Scale (VADL) were used for a self-dizziness scale at the same time. All patients underwent rehabilitation therapy. Subjective visual horizontal/SVV and DHI/VADL were assessed again approximately 4 weeks later. Postrehabilitation SVH/SVV and DHI/VADL data were compared with initial data., Results: Dizziness Handicap Inventory and VADL were improved after 4 weeks of rehabilitation, and the deviation toward ipsilesional side SVH and SVV was also improved., Conclusion: These results demonstrate that SVH and SVV correlated with clinical dizziness symptoms in patients with acute unilateral vestibular neuritis. Therefore, SVH and SVV would be useful tools for the evaluation of clinical manifestations of unilateral vestibular neuritis.

Objective: The purpose of this study was to describe the relation between the Dizziness Handicap Inventory (DHI) and balance performance measures., Study Design: Retrospective case series., Setting: Outpatient balance clinic in a tertiary referral center., Patients: Patients referred with dizziness or imbalance of vestibular and nonvestibular origin., Outcome Measures: DHI, Romberg with Jendrassik maneuver, standing on foam, tandem Romberg, single-leg stance, the timed up and go test, the Dynamic Gait Index (DGI), tandem gait, and the 10-m walking test., Results: The mean age of participants (n = 214) was 53.9 years. The mean DHI total score was 35.1, ranging from 0 to 96. Spearman rank correlation coefficients (rS) between DHI and the static balance tests were fair and ranged between -0.42 (p < 0.01) for single-leg stance with eyes closed and -0.51 (p < 0.01) for single-leg stance with eyes open. Only the Romberg test with Jendrassik maneuver correlated weakly (rS = -0.25; p < 0.01) with the DHI. Correlations with the walking tests were moderate, the connection with the DGI being the strongest one (rS = -0.69; p < 0.01). Forty-two percent of the variance in DHI scores in our patients was accounted for by the DGI score (r = 0.417)., Conclusion: Functional balance tests involving locomotion correlate better with DHI scores when compared with static balance measures. The DGI explains a large component of handicap in dizzy and unsteady patients, which advocates its use in these patients.

Objective: Primary orthostatic tremor is a rare neurologic condition of unknown origin characterized by a 10- to 20-Hz tremor in the legs while standing. Patients with primary orthostatic tremor usually complain of dizziness and unsteadiness that is relieved if they sit down or start to walk around. These patients might be referred to neurotology clinics. Previously, the only way to make the diagnosis has been by means of surface electromyographic recordings from the lower limbs during standing. The authors wanted to study whether posturography can be used to screen for primary orthostatic tremor., Study Design: Retrospective case review., Setting: Balance clinic at a tertiary referral center., Patients: From September 2000 to August 2002, 701 patients were investigated at the authors' balance clinic., Intervention: Static posturography on a force platform with 50-Hz sampling frequency. Recordings were made during 120 seconds of quiescent stance with open or closed eyes., Main Outcome Measure: Fast-Fourier transformation (FFT) analysis of recorded torque in the fore-to-aft direction to quantify the spectral power distribution in the range of 0 to 25 Hz. Visual inspection of power spectrum plots was performed., Results: Five patients (0.7%) were identified (1 man and 4 women; mean age, 56 yr; age range, 36-73 yr) with narrow peaks at 8.5 to 18 Hz in the power spectra of their posturographic recordings. Surface electromyographic recordings during standing confirmed their diagnosis of primary orthostatic tremor., Conclusion: Analysis of power spectra from posturographic recordings is a simple, quick method to screen for primary orthostatic tremor. The condition might be more common than previously assumed. It is important to identify patients with primary orthostatic tremor because they might be misdiagnosed and left without treatment.

Objective: To define and investigate the symptom set known as visual-vestibular mismatch and analyze its nature and occurrence in two groups of patients referred for dizziness., Study Design: Prospective study of two groups of sequentially referred patients complaining of dizziness, imbalance, or both., Setting: A tertiary and quaternary care ambulatory referral center., Patients: Two groups of patients were studied. One was a group of patients who had suffered work-related head trauma and had subsequent complaints of dizziness and/or imbalance. The other was a group of patients referred for dizziness and/or imbalance who had no history of head trauma, work-related injury, or litigation procedures., Interventions: Standard vestibular assessment including computerized dynamic posturography was carried out on all patients. A series of questions was designed to quantify patients' complaints of symptoms of visual-vestibular mismatch, and patients were scored according to their yes/no answers to the five questions., Main Outcome Measures: Results of traditional vestibular tests were correlated with the answers to the questions. Computerized dynamic posturography and electronystagmography results were compared between both symptomatic and nonsymptomatic patients and also between patients who had traumatic and nontraumatic causes of their symptoms., Results: We found no correlation between test results and the presence of visual-vestibular mismatch symptomatology. There does seem to be a connection between the presence of motion sickness symptomatology and the development of visual-vestibular mismatch symptoms., Conclusion: Although visual-vestibular mismatch is of vestibular origin, it is discernible only after obtaining a careful history. It is a genuine symptom set of vestibular origin, and there is a certain group of patients who are more sensitive to this symptom set and who are often debilitated by its presence.

Objective: To evaluate the change in dizziness handicap after translabyrinthine vestibular schwannoma excision., Study Design: Prospective administration of the Dizziness Handicap Inventory preoperatively and at 3 and 12 months postoperatively; retrospective review of case notes., Setting: A tertiary referral neuro-otology clinic., Patients: A total of 100 consecutive patients who had vestibular schwannomas excised between June 1998 and November 2001 and who had completed Dizziness Handicap Inventories preoperatively and at 3 and 12 months postoperatively., Interventions: Translabyrinthine excision of a unilateral sporadic vestibular schwannoma; preoperative and postoperative generic vestibular rehabilitation exercises., Main Outcome Measures: Dizziness Handicap Inventory scores., Results: For most patients, dizziness handicap does not worsen postoperatively. However, for those in whom it does, dizziness handicap becomes significantly worse between preoperative and 3-month postoperative time points but then does not continue to decline. Tumor size, sex, and magnitude of preoperative canal paresis significantly affect the degree of change in handicap. Age, the presence of central vestibular system abnormalities, and the nature of the patient's principal presenting symptom have no effect on this handicap change., Conclusions: These findings help the clinician in counseling the patient preoperatively about dizziness handicap to be expected postoperatively. In particular, the clinician is now able to take an informed and positive stance in the event of a severe canal paresis preoperatively.