Interpretation of the nine-step test for Eustachian tube function should consider mastoid cavity volume.

INTRODUCTION: The modified nine-step test is a classical method for evaluating Eustachian tube function. However, clinical interpretation of the increased maximal difference in middle ear pressure (mdMEP) in the modified nine-step test is unknown. We hypothesised that the different reservoir effects of the mastoid cavity can bias the results of the modified nine-step test. METHODS: A total of 108 consecutive participants (216 ears) were retrospectively screened. Of these, 55 participants (82 ears) who met the inclusion/exclusion criteria were enrolled. The volumetric results of the mastoid cavity, parameters of the modified nine-step test (mdMEP, middle ear pressure, tympanic membrane compliance), and demographic data were analysed. RESULTS: A significant negative correlation was found between mdMEP and mastoid cavity volume (R = .467, p < .001). Ears with mdMEP >70 daPa showed poor pneumatization in the mastoid cavity, with volumes less than 3000 mm3 (10th percentile of all ears analysed). Ears with mastoid cavity volumes lower than the 25th percentile showed a significantly higher mdMEP (p < .001). Patients with mastoid cavity volumes higher than the 75th percentile were significantly younger (p < .001). Multivariate regression analysis for mdMEP showed a good fit (R = .854) using factors including middle ear pressure, admittance and, most importantly, the reciprocal of mastoid volume (Beta = 0.752, p < .001). CONCLUSIONS: The mdMEP, the main parameter of the modified nine-step test, was negatively correlated with the mastoid cavity volume. Therefore, the results of the modified nine-step test should be interpreted with consideration of mastoid cavity volume.

Measurement and modeling of the mechanical impedance of human mastoid and condyle.

Bone conduction devices are used in audiometric tests, hearing rehabilitation, and communication systems. The mechanical impedance of the stimulated skull location affects the performance of the bone conduction devices. In the present study, the mechanical impedances of the mastoid and condyle were measured in 100 Chinese subjects aged from 22 to 67 years. The results show that the mastoid and condyle impedances within the same subject differ significantly and the impedance differences between subjects at the same stimulation position are mainly below the resonance frequency. The mechanical impedance of the mastoid is significantly influenced by age, and not related to gender or body mass index (BMI). While the mechanical impedance of the condyle is significantly affected by BMI, followed by gender, and not related to age. There are some differences in mastoid impedance between the Chinese and Western subjects. An analogy model predicts that the difference in mechanical impedance between the mastoid and condyle leads to a significant difference in the output force of the bone conduction devices. The results can be used to develop improved condyle and mastoid stimulators for the Chinese.

Mapping the vestibular cerebellar evoked potential (VsCEP) following air- and bone-conducted vestibular stimulation.

Vestibular cerebellar evoked potentials (VsCEPs) were recorded from over the occipital and cerebellar regions of the scalp using bone-conducted (BC) stimuli applied at the mastoids (impulsive accelerations and 500 Hz) and 500 Hz acoustic tones (AC). Ten healthy subjects were tested. Electrodes were positioned over the midline (Oz, Iz, CBz) and at 3, 6 and 9 cm intervals lateral to the midline electrodes bilaterally. Additional electrodes were also positioned over posterior neck muscles (SPL1 and SPL2). The largest evoked potentials on average were recorded from the electrodes 3 and 6 cm lateral to the Iz and CBz midline locations. BC stimuli produced short latency potentials on the side contralateral to the stimulated mastoid and were dependent on stimulus polarity. Positive polarity stimuli produced biphasic VsCEPs at approximately 12 and 17 ms (P12-N17) for BC impulses and 10 and 15 ms (P10-N15) for BC 500 Hz stimuli. Following the initial excitation, there was a period of suppression of background activity lasting an average of 16.8 ms for positive polarity BC impulses. Negative polarity stimuli produced later VsCEPs both for BC impulses (P20-N26) and BC 500 Hz (P13-N18). VsCEPs to AC 500 Hz stimuli lateralised to the contralateral side and were larger for right than left ear stimulation. Stimulus polarity (condensation and rarefaction) did not alter the timing of the VsCEPs to AC 500 Hz tones. No evoked response was recorded to somatosensory (median and radial nerve) stimulation. Four patients with cerebellar disease were tested and two showed abnormal VsCEPs with initial negativities. VsCEPs show distinct mapping over the posterior fossa and are likely to reflect climbing fibre responses via crossed otolith-cerebellar pathways.

Air- and Bone-Conducted Sources of Feedback With an Active Middle Ear Implant.

OBJECTIVES: Active middle ear implants (AMEI) have been used to treat hearing loss in patients for whom conventional hearing aids are unsuccessful for varied biologic or personal reasons. Several studies have discussed feedback as a potential complication of AMEI usage, though the feedback pathway is not well understood. While reverse propagation of an acoustic signal through the ossicular chain and tympanic membrane constitutes an air-conducted source of feedback, the implanted nature of the device microphone near the mastoid cortex suggests that bone conduction pathways may potentially be another significant factor. This study examines the relative contributions of potential sources of feedback during stimulation with an AMEI. DESIGN: Four fresh-frozen, hemi-sectioned, human cadaver specimens were prepared with a mastoid antrostomy and atticotomy to visualize the posterior incus body. A Carina active middle ear implant actuator (Cochlear Ltd., Boulder, CO) was coupled to the incus by two means: (1) a stereotactic arm mounted independently of the specimen and (2) a fixation bracket anchored directly to the mastoid cortical bone. The actuator was driven with pure-tone frequencies in 1/4 octave steps from 500 to 6000 Hz. Acoustic sound intensity in the ear canal was measured with a probe tube microphone (Bruel & Kjær, Nærum, Denmark). Bone-conducted vibration was quantified with a single-axis laser Doppler vibrometer (Polytec Inc., Irvine, CA) from both a piece of reflective tape placed on the skin overlying the mastoid and a bone-anchored titanium screw and pedestal (Cochlear Ltd., Centennial, CO) implanted in the cortical mastoid bone. RESULTS: Microphone measurements revealed ear-canal pressures of 60-89 dB SPL, peaking in the frequency range below 2 kHz. Peak LDV measurements were greatest on the mastoid bone (0.32-0.79 mm/s with mounting bracket and 0.21-0.36 mm/s with the stereotactic suspension); peak measurements on the skin ranged from 0.05 to 0.15 mm/s with the bracket and 0.03 to 0.13 mm/s with stereotactic suspension. CONCLUSION: AMEI produce both air- and bone-conducted signals of adequate strength to be detected by the implanted device microphone, potentially resulting in reamplification. Understanding the relative contribution of these sources may play an important role in the development of targeted mitigation algorithms, as well as surgical techniques emphasizing acoustic isolation.

Measurements of inter-cochlear level and phase differences of bone-conducted sound.

Bone-anchored hearing aids are a widely used method of treating conductive hearing loss, but the benefit of bilateral implantation is limited due to interaural cross-talk. The present study measured the phase and level of pure tones reaching each cochlea from a single, mastoid placed bone transducer on normal hearing participants. In principle, the technique could be used to implement a cross-talk cancellation system in those with bilateral bone conductors. The phase and level of probe tones over two insert earphones was adjusted until they canceled sound from a bone transducer (i.e., resulting in perceived silence). Testing was performed in 50-Hz steps between 0.25 and 8 kHz. Probe phase and level results were used to calculate inter-cochlear level and phase differences. The inter-cochlear phase differences of the bone-conducted sound were similar for all three participants showing a relatively linear increase between 4 and 8 kHz. The attenuation characteristics were highly variable over the frequency range as well as between participants. This variability was thought to be related to differences in skull dynamics across the ears. Repeated measurements of cancellation phase and level of the same frequency produced good consistency across sessions from the same participant.

Contrasting phase effects on vestibular evoked myogenic potentials (VEMPs) produced by air- and bone-conducted stimuli.

We have studied the effects of stimulus phase on the latency and amplitude of cVEMPs and oVEMPs by reanalysing data from Lim et al. (Exp Brain Res 224:437-445, 2013) in which alternating phase was used. Responses for the different initial stimulus phase, either positive or negative, were separated and reaveraged. We found that the phase (compressive or rarefactive) of AC 500-Hz stimuli had no significant effect on either latency or amplitude of the responses. Conversely, phase (positive = motor towards subjects) did alter the effects of BC 500-Hz stimulation. For cVEMPs, phase consistently affected initial latency with earlier responses for positive stimuli, while, for stimulation at the mastoid, negative onset phase gave larger responses. For the oVEMP, effects were different for the two sites of BC stimulation. At the forehead, the response appeared to invert, whereas at the mastoid there appeared to be a delay of the initial response. Related to this, the effect of phase for the two sites was opposite: at the mastoid, positive responses were earlier but negative were larger (particularly for long stimuli). At the forehead, the effect was the opposite: negative onset stimuli evoked earlier responses, whereas positive onset evoked larger responses. These findings indicate a basic difference in the way that AC and BC stimuli activate vestibular receptors and also indicate that the effects of phase of BC stimulation depend on location. Stimulus alternation does little to affect the response to AC stimulation but obscures the effects of BC stimuli, particularly for the oVEMP.

Influence of stimulation position on the sensitivity for bone conduction hearing aids without skin penetration.

OBJECTIVE: This study explores the influence of stimulation position on bone conduction (BC) hearing sensitivity with a BC transducer attached using a headband. DESIGN: (1) The cochlear promontory motion was measured in cadaver heads using laser Doppler vibrometry while seven different positions around the pinna were stimulated using a bone anchored hearing aid transducer attached using a headband. (2) The BC hearing thresholds were measured in human subjects, with the bone vibrator Radioear B71 attached to the same seven stimulation positions. STUDY SAMPLE: Three cadaver heads and twenty participants. RESULTS: Stimulation on a position superior-anterior to the pinna generated the largest promontory motion and the lowest BC thresholds. Stimulations on the positions superior to the pinna, the mastoid, and posterior-inferior to the pinna showed similar magnitudes of promontory motion and similar levels of BC thresholds. CONCLUSION: Stimulations on the regions superior to the pinna, the mastoid, and posterior-inferior to the pinna provide stable BC transmission, and are insensitive to small changes of the stimulation position. Therefore it is reliable to use the mastoid to determine BC thresholds in clinical audiometry. However, stimulation on a position superior-anterior to the pinna provides more efficient BC transmission than stimulation on the mastoid.

Acoustical transmission-line model of the middle-ear cavities and mastoid air cells.

An acoustical transmission line model of the middle-ear cavities and mastoid air cell system (MACS) was constructed for the adult human middle ear with normal function. The air-filled cavities comprised the tympanic cavity, aditus, antrum, and MACS. A binary symmetrical airway branching model of the MACS was constructed using an optimization procedure to match the average total volume and surface area of human temporal bones. The acoustical input impedance of the MACS was calculated using a recursive procedure, and used to predict the input impedance of the middle-ear cavities at the location of the tympanic membrane. The model also calculated the ratio of the acoustical pressure in the antrum to the pressure in the middle-ear cavities at the location of the tympanic membrane. The predicted responses were sensitive to the magnitude of the viscothermal losses within the MACS. These predicted input impedance and pressure ratio functions explained the presence of multiple resonances reported in published data, which were not explained by existing MACS models.

Human middle-ear model with compound eardrum and airway branching in mastoid air cells.

An acoustical/mechanical model of normal adult human middle-ear function is described for forward and reverse transmission. The eardrum model included one component bound along the manubrium and another bound by the tympanic cleft. Eardrum components were coupled by a time-delayed impedance. The acoustics of the middle-ear cleft was represented by an acoustical transmission-line model for the tympanic cavity, aditus, antrum, and mastoid air cell system with variable amounts of excess viscothermal loss. Model parameters were fitted to published measurements of energy reflectance (0.25-13 kHz), equivalent input impedance at the eardrum (0.25-11 kHz), temporal-bone pressure in scala vestibuli and scala tympani (0.1-11 kHz), and reverse middle-ear impedance (0.25-8 kHz). Inner-ear fluid motion included cochlear and physiological third-window pathways. The two-component eardrum with time delay helped fit intracochlear pressure responses. A multi-modal representation of the eardrum and high-frequency modeling of the middle-ear cleft helped fit ear-canal responses. Input reactance at the eardrum was small at high frequencies due to multiple modal resonances. The model predicted the middle-ear efficiency between ear canal and cochlea, and the cochlear pressures at threshold.

Electro-acoustic performance of the new bone vibrator Radioear B81: a comparison with the conventional Radioear B71.

OBJECTIVE: The objective is to evaluate the electro-acoustic performance of a new audiometric bone vibrator, the B81 from Radioear Corporation, USA. Comparison will be made with the widely used B71 which has well-known limitations at low frequencies. DESIGN: The B81 is based on the balanced electromagnetic separation transducer (BEST) principle where static forces are counterbalanced so that nonlinear distortion forces are reduced and maximum hearing levels can be increased. STUDY SAMPLE: Maximum hearing level, total harmonic distortion (THD), frequency response, and electrical impedance were measured for six devices of each bone vibrator type on an artificial mastoid. RESULTS: It was found that B81 reaches 10.7-22.0 dB higher maximum (@ THD = 6% or Vin = 6 VRMS) hearing levels than B71 for frequencies below 1500 Hz, and had significantly lower THD up to 1000 Hz. There was no statistically significant difference between their frequency response, except a deviation at the mid frequencies (α = 0.01) where B81 was more efficient and the electrical impedances were practically the same. CONCLUSIONS: In general, B81 had an improved electro-acoustic performance compared to B71 and is compatible with same audiometers. In particular, B81 allows for sensorineural hearing loss to be measured at considerably higher hearing levels than with B71 below 1500 Hz.

Three-dimensional finite element modeling of the human external ear: simulation study of the bone conduction occlusion effect.

A linear three-dimensional (3D) elasto-acoustic finite element model was used to simulate the occlusion effect following mechanical vibration at the mastoid process. The ear canal and the surrounding soft and bony tissues were reconstructed using images of a female cadaver head (Visible Human Project(®)). The geometrical model was coupled to a 3D earplug model and imported into comsol Multiphysics (COMSOL(®), Sweden). The software was used to solve for the sound pressure at the eardrum. Finite element modeling of the human external ear and of the occlusion effect has several qualities that can complement existing measuring and modeling techniques. First, geometrically complex structures such as the external ear can be reconstructed. Second, various material behavioral laws and complex loading can be accounted for. Last, 3D analyses of external ear substructures are possible allowing for the computation of a broad range of acoustic indicators. The model simulates consistent occlusion effects (e.g., insertion depth variability). Comparison with an experimental dataset, kindly provided by Stenfelt and Reinfeldt [Int. J. Audiol. 46, 595-608 (2007)], further demonstrates the model's accuracy. Power balances were used to analyze occlusion effect differences obtained for a silicone earplug and to examine the increase in sound energy when the ear canal is occluded (e.g., high-pass filter removal).

Thresholds for vestibular-evoked myogenic potentials (VEMPs) produced by impulsive transmastoid acceleration.

OBJECTIVE: To evaluate methods for estimating thresholds of vestibular evoked myogenic potentials (VEMPs) and ocular VEMPs (OVEMPs) produced by impulsive transmastoid acceleration (ITA). DESIGN: VEMPs and OVEMPs were obtained simultaneously from subjects in supine posture with both head and eyes elevated. Thresholds to ITA were measured using four different response identification methods. STUDY SAMPLE: Twelve adult subjects with no history of auditory or vestibular deficits. RESULTS: VEMP and OVEMP thresholds were found within the range of -8 to -26 dB re 0.2 g, with overall VEMP thresholds being lower than OVEMP thresholds by average of 3-10 dB, depending on the method used. CONCLUSION: VEMPs can be obtained at lower ITA stimulation levels than OVEMPs. Threshold values depend on the method used to define response presence.

A new technique to investigate vestibulo-spinal reflexes.

Vestibulospinal reflexes can be elicited in humans by low amplitudes direct (galvanic) currents lasting tens of milliseconds and applied across the two mastoids bones, which can be delivered by particular stimulators. The stimulus induces a perception of body sway and a postural response appropriate to counteract the perceived sway. Both the direction of the perceived and induced body sway are modulated by the orientation of the head with respect to the body. This phenomenon is due to the fact that integration of vestibular and neck signals allows to correctly infer the direction of body sway from the labyrinthine input, which is instead related to direction of head motion. The modulation of stimulus-elicited body sway by neck rotation could be utilised for testing the effectiveness of neck proprioceptive signals in modifying the reference frame for labyrinthine signals from the head to the body. In the present experiments we showed that labyrinthine stimulation can be performed also by using train of pulses of 1 msec duration, which can be delivered by virtually all stimulators allowed for human use. Moreover, we developed a simple technique for visualising the time course of the changes in the direction of the postural response, based on the evaluation of the velocity vector of subject's centre of pressure. This method could be exploited in order to the test the efficacy of neck proprioceptive information in modifying the reference frame for processing vestibular signals in both physiological and pathological condition.

Interactions in the cochlea between air conduction and osseous and non-osseous bone conduction stimulation.

Since air-conducted (AC) and clinical (mastoid) bone-conducted (BC) sounds interact in the cochlea (e.g. pitch, cancellation, masking, beats), it has been thought that both AC and BC stimulations lead to a mechanical wave in the cochlea. However, there are also "non-osseous" forms of BC, i.e. auditory sensation produced when the clinical bone vibrator is applied to "non-osseous" soft tissue sites. In the present study, such "non-osseous" sites were identified (e.g. eye, cheek, neck) and they interacted with AC and osseous BC (pitch matching, beats, masking), indicating that all of these forms of auditory stimulation converge in the cochlea, producing the same pattern of mechanical activity, leading to their interactions.

Sex determination using mastoid process measurement in Thais.

BACKGROUND: Analysis of skeleton is necessary for sex determination. There are several pieces of bone that are used such as pelvic bone and zygomatic arch etc. In the fieldwork of physical anthropologist and forensic physician, the skull or some pieces of the skull can be very useful. In the skull, the mastoid process is a compact and permanent process. Craniometric measurements of mastoid process are interesting parameters to distinguish sex. OBJECTIVE: To study the craniometric measurements of mastoid process of dry skulls in Thais and provide a method for sex determination. MATERIAL AND METHOD: One hundred normal skulls of Thais from the central region, 60 male and 40 female, were studied. The measurement of mastoid process between the three points, porion (po), mastoidale (ma), and asterion (as) were made. The three distances (po-ma, ma-as, po-as) were recorded (mm) and the mastoid triangular areas were calculated by using Heron's formula (mm2). The student's t-test and linear discriminant analysis were used for data analysis. RESULTS: The means of mastoid dimensions and mastoid triangular area in male are significantly larger than those of the female (p < or = 0.01). The linear discriminant analysis shows that using the mastoid process dimensions and mastoid triangular area for determining sex in Thais are convincing. The average accuracy is 67.00 to 76.90%. The better mastoid dimension is ma-as of the right mastoid process. It shows a high average accuracy at 76.90%. CONCLUSION: Means of the mastoid dimensions and mastoid triangular area of Thai skulls (whole skull or fragments) provide an accurate method for determining sex.

[The correlation of middle ear pressure variations with mastoid pneumatization during nitrous oxide administration].

BACKGROUND: The present study evaluated the relationship between the middle ear (ME) pressure increase rate (PIR) and the mastoid size as well as the effect of mastoid size on the incidence of nausea and vomiting during nitrous oxide (N2O) anesthesia. METHODS: Twelve healthy male volunteers were recruited. The extent of mastoid pneumatization was measured planimetrically using a mastoid X-ray (Schuller's view). The ears were then divided into a small or large mastoid group according to the median value. The ME pressure was compared just before each increase to 33%, 50%, and 67% N2O. Using the ME pressure curve, the PIR for the first peak of the curve steepness was calculated. RESULTS: Increasing the end-tidal N2O concentration to 50% and 67% in the large mastoid group and to 33%, 50%, and 67% in the small mastoid group significantly increased the ME pressure. The PIR in the ears in the large mastoid group was significantly lower and the incidence of nausea was 33% in the small mastoid group during 33% N2O anesthesia. CONCLUSIONS: A higher PIR in the ears and a higher incidence of nausea were observed in the small mastoid group, compared with the large mastoid group.

Vertical torque responses to vestibular stimulation in standing humans.

The effects of electrical vestibular stimulation upon movement and perception suggest two evoked sensations: head roll and inter-aural linear acceleration. The head roll vector causes walking subjects to turn in a direction dependent on head pitch, requiring generation of torque around a vertical axis. Here the effect of vestibular stimulation upon vertical torque (T(z)) was investigated during quiet stance. With the head tilted forward, square-wave stimuli applied to the mastoid processes evoked a polarity-specific T(z) response accompanied by trunk yaw. Stochastic vestibular stimulation (SVS) was used to investigate the effect of head pitch with greater precision; the SVS­T(z) cross-correlation displayed a modulation pattern consistent with the head roll vector and this was also reflected by changes in coherence at 2­3 Hz. However, a separate response at 7­8 Hz was unaffected by head pitch. Head translation (rather than rotation) had no effect upon this high frequency response either, suggesting it is not caused by a sense of body rotation induced by an inter-aural acceleration vector offset from the body. Instead, high coherence between medio-lateral shear force and T(z) at the same frequency range suggests it is caused by mechanical coupling to evoked medio-lateral sway. Consistent with this explanation, the 7­8 Hz response was attenuated by 90 deg head roll or yaw, both of which uncouple the inter-aural axis from the medio-lateral sway axis. These results demonstrate two vertical torque responses to electrical vestibular stimulation in standing subjects. The high frequency response can be attributed to mechanical coupling to evoked medio-lateral sway. The low frequency response is consistent with a reaction to a sensation of head roll, and provides a novel method for investigating proprioceptive-vestibular interactions during stance.

Lack of otolith involvement in balance responses evoked by mastoid electrical stimulation.

Passing current through mastoid electrodes (conventionally termed galvanic vestibular stimulation; GVS) evokes a balance response containing a short- and a medium-latency response. The origins of these two responses are debated. Here we test the hypotheses that they originate from net signals evoked by stimulation of otolith and semi-circular canal afferents, respectively. Based on anatomy and function, we predicted the directions of the stimulus-evoked net head rotation vector from the canals and the linear acceleration net vector from the otoliths. We tested these predictions in healthy adults by obtaining responses with the head in strategic postures to alter the relevance of the signals to the balance system. Cross-covariance between a stochastic waveform of stimulating current and motor output was used to assess the balance responses. Consistent with the canal hypothesis, with the head pitched down the medium-latency EMG response was abolished while the short-latency EMG response was maintained. The results, however, did not support the otolith hypothesis. The direction of the linear acceleration signal from the otoliths was predicted to change substantially when using monaural stimuli compared to binaural stimuli. In contrast, short-latency response direction measured from ground-reaction forces was not altered. It was always directed along the inter-aural axis irrespective of whether the stimulus was applied binaurally or monaurally, whether the head was turned in yaw through 90 deg, whether the head was pitched down through 90 deg, or combinations of these manipulations. We conclude that a net canal signal evoked by GVS contributes to the medium-latency response whilst a net otolith signal does not make a significant contribution to either the short- or medium-latency responses.

Occipital nerve stimulator placement via a retromastoid to infraclavicular approach: a technical report.

Occipital nerve stimulation is a form of peripheral nerve stimulation used to treat refractory headache disorders. Various techniques have been described for occipital nerve stimulator implantation; these include midline cervical or retromastoid lead insertion with internal pulse generator placement in the infraclavicular, gluteal or low abdominal regions. Lead migration is one of the most common complications of occipital nerve stimulators. Implantation approaches that include remote battery sites may contribute to mechanical stress on the components, as the leads or extensions may traverse highly mobile body regions. In this technical report, we describe an occipital stimulator implantation technique that may be advantageous in terms of patient positioning, ease of surgical approach and minimization of mechanical stress on components.

Effects of viewing distance on ocular vestibular evoked myogenic potentials (oVEMPs) for air- and bone-conducted stimuli at multiple sites.

BACKGROUND: The ocular vestibular evoked myogenic potential is otolith-dependent and has been suggested to be a manifestation of the linear vestibulo-ocular reflex (L-VOR). A characteristic feature of the translational LVOR (t-LVOR) is its dependence on the distance of a target. OBJECTIVE: To assess if viewing distance affects amplitude and latency properties of the ocular vestibular evoked myogenic potential (oVEMPs). METHODS: Bone- and air-conducted (BC and AC) stimuli were used to evoke oVEMPs in 10 healthy subjects. BC stimuli consisted of impulsive accelerations applied at the mastoids, AFz, Oz and Iz. AC stimuli consisted of 500 Hz tones delivered unilaterally to each ear. Target distances of 40 cm (near), 190 cm (intermediate) and 340 cm (far) were used for all stimuli. RESULTS: The largest amplitude oVEMP was obtained from Iz and the latency for AFz was shorter than for BC stimulation at other sites. We found no significant effect of target distance on oVEMP amplitudes for any of the stimuli used. There was a small but significant effect on latency with the nearest target having a longer latency (overall 12.4 ms vs 12.0 ms for the 2 more distant sites). CONCLUSIONS: Previously reported differences between latencies and stimulus sites for midline BC stimulation were confirmed. Target distance had no significant effect on oVEMP amplitude, which suggests it is not modified like other components of the t-LVOR.