Subjective perception of activity level: A prognostic factor for developing chronic dizziness after vestibular schwannoma resection?

Introduction: A vestibular schwannoma (VS) resection causes an acute unilateral vestibular deafferentation resulting in acute postoperative symptoms. Despite the expected resolution of most of the symptoms, due to central vestibular compensation, more than one out of four patients develop chronic dizziness. Several predictive factors, such as age and tumor size, have been suggested. Despite its potential effect on the process of central vestibular compensation, the level of physical activity after VS resection was not yet considered. Therefore, the association between the level of physical activity and chronic dizziness after VS resection will be investigated. Methods: This retrospective cohort study included 66 patients who underwent a retro-sigmoid VS resection between October 2001 and February 2007. Patients were assessed before surgery and at 9 weeks and 6 months postoperatively. At 9 weeks, patients were asked to report their level of physical activity (PA) during the past week by using a visual analogue scale and their balance performance was assessed by four standing balance conditions with eyes closed and the Timed Up and Go test (TUG). Based on the Dizziness Handicap Inventory (DHI) score at 6 months, patients were divided in a chronic dizziness group (DHI > 30) and non-chronic dizziness group (DHI-score ≤ 30). Age, sex, Koos classification, preoperative vestibular function, treatment group, balance performance, and level of PA were compared between both groups and used as independent variables in linear regression analyses with the DHI score at 6 months as dependent variable. Results: The chronic dizzy patients revealed to have significantly lower levels of PA (p < 0.001) and worse static and dynamic balance performance (p = 0.023 and p = 0.041, respectively) 9 weeks after surgery. After elimination, the multiple regression analysis resulted in a model with two variables (PA level, TUG) which significantly predicted the DHI score (F 2,42 = 6.581; R 2 = 0.239; p = 0.003). Conclusion: This study revealed associations between (1) the level of PA and balance performance in the subacute phase and (2) chronic dizziness after VS resection. Assessment of the level of PA and balance performance during the subacute phase, which can be performed in a non-invasive and non-time-consuming way, might therefore provide prognostic information after VS resection.

Three Years of Vestibular Infant Screening in Infants With Sensorineural Hearing Loss.

OBJECTIVES: Although vestibular deficits are more prevalent in hearing-impaired children and can affect their development on many levels, a pediatric vestibular assessment is still uncommon in clinical practice. Since early detection may allow for timely intervention, this pioneer project has implemented a basic vestibular screening test for each six-month-old hearing-impaired infant in Flanders, Belgium. This study aims to report the vestibular screening results over a period of three years and to define the most important risk factors for abnormal vestibular screening results. METHODS: Cervical Vestibular Evoked Myogenic Potentials with bone-conduction were used as a vestibular screening tool in all reference centers affiliated to the Universal Newborn Hearing Screening Program in Flanders. From June 2018 until June 2021, 254 infants (mean age: 7.4 months, standard deviation: 2.4 months) with sensorineural hearing loss were included. RESULTS: Overall, abnormal vestibular screening results were found in 13.8% (35 of 254) of the infants. The most important group at risk for abnormal vestibular screening results were infants with unilateral or bilateral severe to profound sensorineural hearing loss (20.8%, 32 of 154) (P < .001, odds ratio = 9.16). Moreover, abnormal vestibular screening results were more prevalent in infants with hearing loss caused by meningitis (66.7%, 2 of 3), syndromes (28.6%, 8 of 28), congenital cytomegalovirus infection (20.0%, 8 of 40), and cochleovestibular anomalies (19.2%, 5 of 26). CONCLUSIONS: The vestibular screening results in infants with sensorineural hearing loss indicate the highest risk for vestibular deficits in severe to profound hearing loss, and certain underlying etiologies of hearing loss, such as meningitis, syndromes, congenital cytomegalovirus, and cochleovestibular anomalies.

Vestibular Infant Screening (VIS)-Flanders: results after 1.5 years of vestibular screening in hearing-impaired children.

Due to the close anatomical relationship between the auditory and vestibular end organs, hearing-impaired children have a higher risk for vestibular dysfunction, which can affect their (motor) development. Unfortunately, vestibular dysfunction often goes unnoticed, as vestibular assessment in these children is not standard of care nowadays. To timely detect vestibular dysfunction, the Vestibular Infant Screening-Flanders (VIS-Flanders) project has implemented a basic vestibular screening test for hearing-impaired infants in Flanders (Belgium) with a participation rate of 86.7% during the first year and a half. The cervical Vestibular Evoked Myogenic Potentials (cVEMP) test was applied as vestibular screening tool to map the occurrence of vestibular (mainly saccular) dysfunction in this population. At the age of 6 months, 184 infants were screened. No refers on vestibular screening were observed in infants with permanent conductive hearing loss. In infants with permanent sensorineural hearing loss, a cVEMP refer rate of 9.5% was observed. Failure was significantly more common in infants with severe-profound compared to those with mild-moderate sensorineural hearing loss (risk ratio = 9.8). Since this is the first regional study with a large sample size and successful participation rate, the VIS-Flanders project aims to set an example for other regions worldwide.

Does 'cochlear Ménière's disease' exist? An electrocochleographic and audiometric study.

INTRODUCTION: According to current diagnostic criteria, patients exhibiting only cochlear symptoms without vertigo cannot be diagnosed with Ménière's disease (MD). The recently reported Ménière's Disease Index (MDI) combines audiometric and electrocochleographic parameters in a multidimensional measure correlating with the clinical degrees of MD. MATERIALS AND METHODS: Twenty-one patients with hearing loss, tinnitus and aural fullness, but without vertigo, underwent transtympanic electrocochleography. Based on the previously reported formula, the MDI value for every patient was calculated. RESULTS: Mean MDI value was 5.7 on a scale from 0 (mean value of non-MD patients) to 10 (mean value of definite MD patients). CONCLUSIONS: We can thus hypothesize that, based on audiometry and electrocochleography, 'cochlear MD' patients may represent a separate clinical entity with Ménière-like pathophysiology or underlying endolymphatic hydrops.

The Ménière's Disease Index: an objective correlate of Ménière's disease, based on audiometric and electrocochleographic data.

INTRODUCTION: Diagnosis of Ménière's disease (MD) is made according to the diagnostic criteria proposed by the American Academy of Otolaryngology-Head and Neck Surgery. Value of transtympanic electrocochleography (TT-ECoG) in diagnosis of endolymphatic hydrops remains controversial. The aim of our study is to determine which combination of audiometric and electrocochleographic measures correlates best with the clinical diagnosis of endolymphatic hydrops. MATERIALS AND METHODS: Retrospective analysis of 109 consecutive patients undergoing TT-ECoG. All 131 tested ears were divided in categories: definite MD, probable MD, possible MD, and non-MD, according to the criteria of the American Academy of Otolaryngology-Head and Neck Surgery. TT-ECoG was performed using clicks and tone burst stimuli. Audiometric and electrocochleographic data were collected and analyzed. RESULTS: TT-ECoG with tone burst stimuli correctly identified 91% of the definite MD group and 71% of the non-MD group. Using binary logistic regression followed by discriminant analysis, we found a linear combination of 3 variables (air-conduction threshold at 125 and 8,000 Hz, and TT-ECoG summating potential amplitude at 4,000 Hz) that showed a good correlation with the clinical diagnosis of definite MD. This combination was able to identify 98% of the non-MD cases and 94% of the definite MD cases. The Ménière's Disease Index was created to scale the degree of MD from 0 (non-MD) to 10 (definite MD). CONCLUSION: The Ménière's Disease Index is an objective measure that correlates with the clinical degrees of MD. Future validation is still needed to confirm the added diagnostic and clinical value of this method.

Failure of gamma-aminobutyrate acid-beta agonist baclofen to improve balance, gait, and postural control after vestibular schwannoma resection.

INTRODUCTION: Incomplete postural control often occurs after vestibular schwannoma (VS) surgery. Customized vestibular rehabilitation in man improves and speeds up this process. Animal experiments have shown an improved and faster vestibular compensation after administration of the gamma-aminobutyrate acid (GABA)-beta agonist baclofen. OBJECTIVE: To examine whether medical treatment with baclofen provides an improvement of the compensation process after VS surgery. DESIGN: A time-series study with historical control. SETTING: Tertiary referral center. METHODS: Thirteen patients who underwent VS resection were included and compared with a matched group of patients. In addition to an individualized vestibular rehabilitation protocol, the study group received medical treatment with 30 mg baclofen (a GABA-beta agonist) daily during the first 6 weeks after surgery. MAIN OUTCOME MEASURES: Clinical gait and balance tests (Romberg maneuver, standing on foam, tandem Romberg, single-leg stance, Timed Up & Go test, tandem gait, Dynamic Gait Index) and Dizziness Handicap Inventory. Follow-up until 24 weeks after surgery. RESULTS: When examining the postoperative test results, the group treated with baclofen did not perform better when compared with the matched (historical control) group. Repeated-measures analysis of variance revealed no significant group effect, but a significant time effect for almost all balance tests during the acute recovery period was found. An interaction effect between time and intervention was seen concerning single-leg stance and Dizziness Handicap Inventory scores for the acute recovery period. CONCLUSION: Medical therapy with baclofen did not seem to be beneficial in the process of central vestibular compensation.

The effect of early customized vestibular rehabilitation on balance after acoustic neuroma resection.

OBJECTIVE: To compare the effect of early customized vestibular rehabilitation with general instructions in patients after acoustic neuroma surgery. SETTING: Tertiary referral centre. SUBJECTS: Fifty-three patients after surgery. DESIGN: A prospective assessor-blinded, randomized controlled trial. INTERVENTIONS: After stratification for age (<50 years; >or=50 years), patients were randomly allocated into groups receiving general instructions or customized vestibular rehabilitation protocols for 12 weeks. OUTCOME MEASURES: Standing Balance Sum, Timed Up and Go test, Tandem Gait and Dynamic Gait Index. Balance performance was assessed preoperatively, at discharge (one week after surgery), three, six, nine, 12, 26 and 52 weeks after surgery. RESULTS AND DISCUSSION: All subjects clearly improved within the first six weeks after surgery. However, older subjects receiving vestibular rehabilitation performed significantly (P<0.05) better on standing balance, Timed Up and Go test and Tandem Gait, when compared with the older group that received only general instructions. This effect persisted up to 12 weeks and also became apparent on the Dynamic Gait Index. In addition, the older vestibular rehabilitation group had better balance scores at 12 weeks when compared with their original preoperative scores (P<0.05). This pattern remained even up to one year after surgery (P<0.05). CONCLUSION: In patients over 50, early vestibular rehabilitation facilitates recovery of postural control after acoustic neuroma surgery. Customized vestibular rehabilitation should be given in addition to general instructions that stress the need of exposure to movement. Retention of the early beneficial effects even one year after surgery stresses the importance of customized vestibular rehabilitation.

Travelling wave velocity test and Ménière's disease revisited.

Transtympanic Electrocochleography (TT-ECoG) and the glycerol test can aid in the diagnostic process of Ménière's disease (MD). Measurement of travelling wave velocity (TWV) has been proposed as an alternative to TT-ECoG to detect endolymphatic hydrops. We assessed the feasibility and obtained normative data of the TWV test in the diagnosis of MD, and compared the test results in MD patients with their symptoms and their TT-ECoG results. The TWV test records two runs of auditory brainstem responses to clicks that are ipsilaterally masked with two different high pass filtered noise bands. The resulting latency difference of peak V was used as a measure of the TWV. The 95% confidence interval of this latency difference was defined in a group of 28 normals. Subsequently, the test was performed in nine MD patients. After the TWV test, seven of these patients underwent a TT-ECoG. The symptoms of MD patients at the time of testing and their TT-ECoG results were compared with TWV test results. The 95% confidence interval of the latency difference of peak V in the control group was 0.190-0.668 ms. A latency difference <0.190 ms indicates an increase in TWV, and thus reflects a positive test. In nine MD patients, we found a clear correlation between the result of the TWV test and TT-ECoG. The TWV test result did not significantly correlate with a single symptom. Our findings suggest that the TWV test can be useful to detect endolymphatic hydrops, but further experiments with larger patient groups are needed to confirm the diagnostic value of the TWV test.

Lack of diagnostic value of high-pass noise masking of auditory brainstem responses in Ménière's disease.

INTRODUCTION: Different electrophysiologic tests were developed to ascertain or detect endolymphatic hydrops (ELH). Recently, Cochlear Hydrops Analysis Masking Procedure (CHAMP), a new auditory brainstem response (ABR) technique, proved to be able to separate normal controls from definite Ménière's disease (MD) with 100% sensitivity and 100% specificity. OBJECTIVE: To evaluate the applicability and diagnostic value of CHAMP in a series of MD and non-MD patients with otovestibular complaints. STUDY DESIGN: An observational retrospective study. SETTING: Tertiary referral centre. PATIENTS: Forty-five patients, of which 28 patients had MD. INTERVENTIONS: Cochlear Hydrops Analysis Masking Procedure test was conducted, and audiometric data and clinical information were collected. All responses were blindly evaluated and divided into three categories: (1) test suggestive for cochlear/ELH, (2) test within normal ranges, and (3) test not interpretable. MAIN OUTCOME MEASURES: Sensitivity and specificity, evaluation of diagnostic value. RESULTS: Forty-nine percent of the tests were found to be not interpretable. Of the remaining responses, 13 tests were suggestive for ELH, and 16 tests were within normal ranges. This yields a sensitivity of 31% and a specificity of 28%. There was no significant difference between the mean latency difference (mean [SD]) for Wave V of the MD group (0.43 ms [0.37]) and the non-MD group (0.65 ms [0.44]). Using logistic regression analysis, we found that CHAMP test did not contribute to the ability to discriminate between hydropic and nonhydropic ears. CONCLUSION: In contrast to studies assessing CHAMP performance in Ménière patients and normal controls, the present study revealed this new test offers no discriminative value in differentiating Ménière's from non-MD subjects with otovestibular symptoms.

Conscientiousness in patients with Ménière's disease.

OBJECTIVE: To assess whether a conscientious personality profile is more prevalent in patients with Ménière's disease (MD) in comparison with other vertigo patients. Second, to investigate a sex effect and compare the obtained conscientiousness scores with published normative values. PATIENTS: A total of 108 patients were included and subdivided into one of five pathology groups: MD, benign paroxysmal positional vertigo, vestibular neuritis, vestibular schwannoma, and posttraumatic nonbenign paroxysmal positional vertigo. INTERVENTION: The conscientiousness domain of the self-reporting NEO Five-Factor Inventory questionnaire. MAIN OUTCOME MEASURE: Conscientiousness score. RESULTS: There was no significant difference between the diagnostic groups or a sex effect. MD patients had a higher score than published normal values. CONCLUSION: As assessed with the NEO Five-Factor Inventory questionnaire, MD patients do not demonstrate a higher conscientious personality profile in comparison with other vertigo patients. Therefore, this limits the clinical use of the personality profile to discriminate between patient groups.