Tone-induced cervical and ocular vestibular-evoked myogenic potentials: comparing abnormalities in traumatic and non-traumatic vestibular disease.

BACKGROUND: Otolithic function is poorly understood, but vestibular-evoked myogenic potential testing has allowed the documentation of pathology in patients who complain of imbalance. METHODS: Seventy-four patients with traumatic and non-traumatic vestibular disease were sequentially assessed at a tertiary referral neuro-otology unit in a teaching hospital. A detailed history of all patients was taken and standard vestibular assessment was conducted using the technique described in the companion paper. The results of both groups of patients were analysed and the rate of abnormalities was assessed. RESULTS: There was a high rate of abnormalities, including bilateral pathology, in a significant number of patients. Many patients in both groups inexplicably failed to recover. CONCLUSION: Vestibular-evoked myogenic potentials are helpful in documenting pathology, including bilateral pathology, which is outlined in the literature as being exceedingly difficult to compensate for.

Performing and analysing tone-induced cervical and ocular vestibular-evoked myogenic potentials in traumatic and non-traumatic vestibular pathology.

OBJECTIVE: This paper discusses our technique of carrying out cervical and ocular vestibular-evoked myogenic potential testing in a single position. The described technique allows for a symmetrical, natural flexion of the neck muscles, which is helpful as many of our patients have suffered traumatic deceleration injures. METHODS: Patients with suspected vestibular pathology referred by specialists were sequentially assessed in a tertiary referral neuro-otology unit within a teaching hospital using our technique and our previously established normative database. All patients underwent standardised vestibular assessment in addition to cervical and ocular vestibular-evoked myogenic potential assessment. Our normative data are in keeping with that reported by other centres. RESULTS: Many of the patients had abnormal vestibular-evoked myogenic potentials, which is in line with a history suggesting otolithic disease. CONCLUSION: Both cervical and ocular vestibular-evoked myogenic potentials offer several parameters for detecting abnormalities. The technique reported enables us to assess patients in an accurate fashion whether or not they have suffered traumatic neck injuries.

A multidisciplinary management of a type III dens invaginatus in a maxillary permanent canine.

BACKGROUND: Dens invaginatus affects 0.3-10% of the population; however, few reports document its occurrence in maxillary canines. Management of associated periradicular infections is often challenging. The benefits of computed tomography are well documented in these situations, providing greater clinical information for diagnosis, prognosis and practical management. Many previous reports in the literature utilise this technology but often focus on an endodontic management approach. CASE REPORT: Details of the treatment of a complex type III invagination affecting a maxillary canine, combined with hypodontia and malocclusion is described. Endodontic treatment was deemed inappropriate resulting in extraction of the invaginated canine. The multidisciplinary planning and approach, highlighted the need for close teamwork, shared care and a patient-centred approach. FOLLOW-UP: A 5-year follow-up and review recorded a successful outcome. CONCLUSIONS: This case reinforces the importance of careful investigation and planning in ensuring an optimal outcome when addressing multiple dental anomalies. Extensive consideration of the initial treatment strategy is required, coupled with evaluation of the outcome and longevity of any potential treatment modality to be employed. The consideration of inevitable future restorative treatment is fundamental, highlighting the importance of multidisciplinary planning at diagnosis. Moreover, orthodontic, aesthetic, behavioural and/or social factors may further complicate management in adolescents.

Measuring caloric response: comparison of different analysis techniques.

INTRODUCTION: Electronystagmography (ENG) testing has been supplanted by newer techniques of measuring eye movement with infrared cameras (VNG). Most techniques of quantifying caloric induced nystagmus measure the slow phase velocity in some manner. Although our analysis is carried out by very experienced assessors, some systems have computer algorithms that have been "taught" to locate and quantify maximum responses. We wondered what differences in measurement might show up when measuring calorics using different techniques and systems, the relevance of this being that if there was a change in slow phase velocity between ENG and VNG testing when measuring caloric response, then normative data would have to be changed. There are also some subjective but important aspects of ENG interpretation which comment on the nature of the response (e.g. responses which might be "sporadic" or "scant"). METHODS: Our experiment compared caloric responses in 100 patients analyzed four different ways. Each caloric was analyzed by our old ENG system, our new VNG system, an inexperienced assessor and the computer algorithm, and data was compared. CONCLUSIONS: All four systems made similar measurements but our inexperienced assessor failed to recognize responses as sporadic or scant, and we feel this is a limitation to be kept in mind in the rural setting, as it is an important aspect of assessment in complex patients. Assessment of complex VNGs should be left to an experienced assessor.

Cerebellar vermis lesions and tumours of the fourth ventricle in patients with positional and positioning vertigo and nystagmus.

Positional and positioning vertigo and nystagmus syndromes are usually due to peripheral vestibular dysfunction. The most common form is benign paroxysmal positioning. In this paper, we discuss more serious aetiologies in the differential diagnosis for patients presenting with a history suggestive of benign paroxysmal positioning vertigo. We draw attention to the diagnosis of cerebellar vermis lesions and tumours of the fourth ventricle by presenting two cases of patients with positional nystagmus of so called benign paroxysmal type. We review the literature on positional nystagmus, highlighting key findings on history and physical examination to aid in the correct diagnosis of benign paroxysmal positioning vertigo, and to differentiate it from the rare yet sinister central aetiologies that can present with positional vertigo of the benign positional type. This is with the aim to avoid over-investigating a common presentation without missing a serious diagnosis.

A new set of criteria for evaluating malingering in work-related vestibular injury.

OBJECTIVE: To develop and use a set of criteria using computerized dynamic posturography results to detect aphysiologic behavior in patients with complaints of imbalance, and to compare the efficacy of this system with present quantitative techniques and with subjective methods of evaluating malingerers. STUDY DESIGN: Prospective study of two groups of sequentially referred patients complaining of dizziness and/or imbalance. 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. MAIN OUTCOME MEASURES: All patients in both groups were scored for aphysiologic behavior using a quantified formula that has been used to detect malingerers, an analysis criterion using different aspects of computerized dynamic posturography performance that has been used for some time, and our newly developed nine-point scoring method. Results of all three methods were compared to determine the effectiveness of each one in detecting malingering behavior. RESULTS: Our nine-point protocol was effective in assessing patients in a consistent manner. Assessment using the quantitative formula in the literature raised suspicions of malingering in many patients with no known ulterior motives, some of whom had documented vestibular disease. Our criteria also evaluate other aspects of performance not evaluated by the presently used techniques. CONCLUSION: Our newly developed criteria are effective at evaluating the medicolegal patients from both the quantitative and qualitative viewpoints, and provide a more thorough assessment than has previously been available.

Visual vestibular mismatch in work-related vestibular injury.

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.

"Across the board" posturography abnormalities in vestibular injury.

OBJECTIVE: To analyze a newly defined group of Computerized Dynamic Posturography abnormalities and to determine if these patients' abnormalities are of vestibular origin. STUDY DESIGN: Analysis of results drawn from our larger study of two groups of sequentially referred patients complaining of dizziness and/or imbalance. SETTING: A tertiary and quaternary care ambulatory referral centre. 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. MAIN OUTCOME MEASURES: CDP results of all patients were reanalyzed and all results were pulled which were abnormal on at least 5 of 6 sensory conditions. All results were analyzed using a quantitative method of detecting malingering and also using our newly developed nine point subjective/objective criteria scale. RESULTS: While the standardized formulae categorized most of these results as "aphysiologic," our nine-point protocol showed most of the patients to be legitimate. CONCLUSIONS: These results represent a legitimate subgroup of vestibular patients that we feel have been more or less unrecognized, many of whom are incapacitated by imbalance and disorientation. These results also are helpful in measuring safety of these patients in the workplace.

Caloric response does not decline with age.

Complaints of imbalance in the elderly are commonly heard by clinicians, and pathology of the vestibular system may play an important role in these complaints. While there is solid anatomical evidence for age related decline of some vestibular structures, a corresponding deterioration in physiologic function has not been convincingly demonstrated. Vestibular function is traditionally measured with caloric irrigations. Although there has been some age dependent change in caloric response shown, there is no good parallel between caloric response and imbalance in the elderly patient. Our experiment confirms that slow phase velocity of caloric responses does not decline with age. Calorics measure only one part of the vestibular system, and so should not be regarded as representative of balance system function. As a result, measured caloric response does not parallel documented anatomic age-related decline of the vestibular system.

Low-dose intratympanic gentamicin treatment for dizziness in Ménière's disease.

OBJECTIVE: Intratympanic gentamicin is used to control dizziness of Ménière's disease, with a low rate of morbidity and a high success rate. We aimed to develop a new technique and schedule of therapy using a lower dose. DESIGN: A retrospective chart review in Ménière's disease patients treated for intractable dizziness. SETTING: A tertiary/quaternary care outpatient setting. METHODS: Patients were administered intratympanic gentamicin using a low-dose protocol on 2 successive days and evaluated with pre- and post-treatment audiovestibular assessment. MAIN OUTCOME MEASURES: Standard evaluation methods of audiovestibular function measured pre- and postfunction of hearing and balance to determine the effects of treatment and morbidity in the form of hearing loss. A telephone follow-up survey was also undertaken. RESULTS: Patients reported satisfactory control of dizziness, with little morbidity in the form of hearing loss. We also found that the use of a myringotomy tube could be precluded. Post-treatment symptoms of imbalance reported by patients settled as patients compensated. In a telephone survey conducted some years after treatment, patient satisfaction was found to be high. CONCLUSIONS: This two-dose regime was shown to be effective in controlling dizzy spells. In patients refractory to the initial two-dose treatment, a follow-up course of treatment usually proved effective. Long-term follow-up of patients seems to show that failure of treatment usually occurs within the first few months, and that symptoms, once controlled, rarely recur.

Effects of dimenhydrinate on computerized dynamic posturography.

OBJECTIVE: Previous studies have demonstrated that sedatives and antiemetics commonly used by patients suppress the vestibulo-ocular reflexes during electronystagmography, making it more difficult to quantify function in such patients. The effects of these medications on computerized dynamic posturography (CDP) have not been studied, and the influences, if any, on the vestibulospinal reflexes are not known. We aimed to study the influence, if any, of dimenhydrinate on CDP performance. DESIGN: A double-blinded study using a randomized protocol to compare the effects of dimenhydrinate and placebo on CDP performance in normal subjects. SETTING: A tertiary/quaternary care facility using a standardized CDP assessment protocol. METHODS: After a CDP training session (one assessment) to rule out any learning effect, 10 subjects underwent CDP assessment on 2 separate days after ingestion of either a standard single dose of dimenhydrinate or placebo. MAIN OUTCOME MEASURES: Pre- and post-medication CDP performance was measured using Sensory Organization Test (SOT) composite scores and also scores on CDP conditions particularly sensitive to measurement of vestibular impairment (SOT conditions 5 and 6). RESULTS: Analysis of data showed no significant effect on CDP performance of normal subjects after dimenhydrinate administration, although there may be a trend toward a slight effect on performance. CONCLUSIONS: There seems to be no significant effect of dimenhydrinate on CDP performance in normal subjects, although there may be a trend. Further studies using a dose causing more significant symptoms or using a higher number of subjects may clarify this.

Specific vocalized complaints in whiplash and minor head injury patients.

OBJECTIVE: Subtle complaints of visual-vestibular mismatch may not be elicited in an initial history-taking. Clinicians must be familiar with the nature of these complaints when assessing whiplash patients because other injuries may predominate and patients do not volunteer these more subtle complaints, which may be persisting and sometimes debilitating. STUDY DESIGN: A retrospective case review was performed. SETTING: The study was conducted at a tertiary/quaternary referral clinic. PATIENTS: Patients with whiplash, mild head injury, or both were referred for assessment of symptoms persisting for at least 2 years after their injury. INTERVENTIONS: A full history; otolaryngologic examination; including assessment of eye movements, corneal reflexes, and gait; investigation including electronystagmography and computerized dynamic posturography; and history-taking and detailed recording of related complaints were performed immediately before diagnostic workup. MAIN OUTCOME MEASURES: Many patients had more subtle complaints, which we now recognize as indicative of vestibular pathology, that have not previously been described in detail in the literature and are often generalized using terms such as "dizziness" or "lightheadedness." It is important to take a detailed history from these patients to delineate their more subtle complaints, because their symptoms frequently do not "fit" into traditional syndromes. RESULTS: Complaints verbalized by patients were tabulated. On more careful analysis, they can be identified as arising from a mismatch between vestibular information and other sensory information used to maintain balance. CONCLUSIONS: Many patients with the standard vestibular syndromes have the same subtle complaints (apart from the standard vertiginous complaints) that patients with whiplash and minor head injury verbalize. The similarity of the complaints in the two groups indicate that the subtle symptoms are caused by underlying vestibular disease.

Dizziness from whiplash and head injury: differences between whiplash and head injury.

OBJECTIVE: Large discrepancies exist in the literature regarding incidence and types of symptomatology in whiplash. This is because of the evolution of whiplash injury over the years with the advent of head rests and seat belts. Previous authors have regarded symptoms of dizziness as a result of brainstem or cerebellar injury or both. It has been difficult in those studies to ascribe a mechanism of injury, as patients with whiplash injury only have been grouped with those who have incurred mild traumatic brain injury as a result of a significant blow to the head. The authors saw the need to delineate patients who had suffered whiplash injury from those who also had suffered mild head injury, as defined in the rehabilitation-neurosurgical literature, to attempt to define differences in symptoms, abnormalities, and mechanisms of recovery in these two groups. STUDY DESIGN: The study design was a retrospective case review. SETTING: The study was conducted at a tertiary-quaternary referral clinic. PATIENTS: The records of 36 patients were reviewed. Nineteen of these patients suffered a whiplash-associated disorder and 17 suffered a mild head injury as well. These patients were referred for assessment of symptoms persisting for at least 2 years after their injury. Patients were excluded if they had not completed clinical assessment, including electronystagmography (ENG) and computerized dynamic posturography (CDP). INTERVENTIONS: A full history, otolaryngologic examination, including assessment of eye movements, corneal reflexes and gait, as well as an investigation, including ENG and CDP, and history taking and detailed recording of related complaints immediately before diagnostic work-up were performed. MAIN OUTCOME MEASURES: Symptoms reported by patients who had received either whiplash alone or whiplash plus mild head trauma as defined in the literature were measured. Patients were classified according to type of accident, type of injury suffered, and degree and nature of posturographic abnormalities. RESULTS: Patients often have similar complaints regardless of whether or not they had suffered a head injury. Although CDP showed abnormalities in both groups, standard ENG assessment, including caloric testing, showed abnormalities only in the head-injured group. The posturographic abnormalities also were analyzed in both groups, and it was found that there was a correlation between the type of posturographic abnormality and the type of injury suffered. Although ENG testing is done routinely, posturography is shown to be more sensitive in picking up abnormalities. In addition, the authors have shown that posturography can delineate the type of injury suffered by exhibiting the compensation strategy used as well as the efficacy of that compensation strategy. CONCLUSIONS: Because ENG abnormalities are limited to patients who have suffered a head injury, the inference is that these two groups of patients have suffered damage at different sites along the balance system pathways, but both of these lesions can lead to similar symptoms. Although the mechanisms of whiplash injury and how they affect the vestibular system are poorly understood, posturography testing is essential in inferring how a patient is recovering by measuring how and how well the patient is overcoming his or her deficit. This has important medical legal implications regarding legitimizing a patient's problem, prognostic factors, as well as rehabilitation plans, measures, and outcomes.

Superficial siderosis--a cause of audiovestibular failure.

Bilateral vestibular end organ failure in adult life is a rare condition with some specific known causes, such as relapsing polychondritis, autoimmune inner ear disease, Lues venerium, and an acute effect of gentamicin. This case report draws attention to a rare condition that is potentially recognizable early in its development. The patient has superficial siderosis, which is iron deposits over the cerebrum, resulting in progressive neurologic failure involving all of the systems. Early in its course before other symptoms appear, there is development of progressive hearing loss and vestibular failure. This case report and literature review are given, including a potential for attempts at therapy if the disorder is recognized early.

Effect of age and training schedules on balance improvement exercises using visual biofeedback.

There has been a growing popularity and success rate of balance rehabilitation programs, and this success is paralleled by the growth of technology, making available instruments that provide objective, quantitative, and immediate results. The Balance Master is such a commercially available instrument, consisting of a dual-force platform connected to a micro-computer that provides visual feedback of the centre of gravity (COG) in relation to the theoretical limits of stability. Spontaneous body sway can be measured in a static central position, or in peripheral positions around the limits of stability (peripheral sway area). The trajectory between targets can also be analyzed in terms of time (transition time) and accuracy (path error) of transition, which gives a quantitative measure of dynamic movement of the COG. This study examined the practice effect that occurs while using this instrument over repeated sessions for two schedules of training (daily and weekly) and over two age groups (20-35 years, and 60-75 years). Each group completed a series of postural exercises, with an assessment of static and dynamic postural variables before and after training, and at approximately 3 and 6 weeks post-training. Spontaneous body sway was measured with eyes open, eyes closed, and with visual feedback of the COG. No significant changes were observed in these variables as measured over the four standard assessment occasions. Peripheral sway area and path error decreased significantly for both the daily and weekly training groups from pre- to post-training, and these skills were retained over both retention tests, whereas the tendency toward decreasing transition time was not significant.(ABSTRACT TRUNCATED AT 250 WORDS)

Topical gentamicin vestibular toxicity.

Two patients with large tympanic membrane perforations received Garasone eardrops. They developed severe acute vestibular deafferentation. In one patient, the middle ear mucosa was healthy and uninfected, and in the other ear, it was inflamed. It is recommended that caution be used in administration of Garasone to the middle ear. If damage can occur with gentamicin, it likely occurs with other ototoxic agents. It is recommended that ototoxic agents not be used in uninflamed middle ears during surgery. The patient should be instructed to treat the discharge through a perforation or tube for only 2 days after the discharge from the external canal ceases.