Vestibular and balance function in veterans with chronic dizziness associated with mild traumatic brain injury and blast exposure.

The purpose of this study was to examine vestibular and balance function in individuals with chronic dizziness associated with mTBI/blast. A prospective case-control study design was used to examine ocular motor, vestibular function, and postural stability in veterans with symptoms of dizziness and/or imbalance following an mTBI or blast exposure (n = 77) and a healthy control group (n = 32). Significant group differences were observed for saccadic accuracy, VOR gain during slow harmonic acceleration at 0.01 Hz, cervical vestibular evoked myogenic potentials asymmetry ratio, composite equilibrium score on the sensory organization test, total Dynamic Gait Index score, and gait. The frequency of test abnormalities in participants with mTBI/blast ranged from 0 to 70% across vestibular, ocular motor, and balance/gait testing, with the most frequent abnormalities occurring on tests of balance and gait function. Seventy-two percent of the mTBI/blast participants had abnormal findings on one or more of the balance and gait tests. Vestibular test abnormalities occurred in ~34% of the individuals with chronic dizziness and mTBI/blast, and abnormalities occurred more frequently for measures of otolith organ function (25% for cVEMP and 18% for oVEMP) than for measures of hSCC function (8% for SHA and 6% for caloric test). Abnormal ocular motor function occurred in 18% of the mTBI/blast group. These findings support the need for comprehensive vestibular and balance assessment in individuals with dizziness following mTBI/blast-related injury.

Effects of Noise Exposure on the Vestibular System: A Systematic Review.

Despite our understanding of the impact of noise-induced damage to the auditory system, much less is known about the impact of noise exposure on the vestibular system. In this article, we review the anatomical, physiological, and functional evidence for noise-induced damage to peripheral and central vestibular structures. Morphological studies in several animal models have demonstrated cellular damage throughout the peripheral vestibular system and particularly in the otolith organs; however, there is a paucity of data on the effect of noise exposure on human vestibular end organs. Physiological studies have corroborated morphological studies by demonstrating disruption across vestibular pathways with otolith-mediated pathways impacted more than semicircular canal-mediated pathways. Similar to the temporary threshold shifts observed in the auditory system, physiological studies in animals have suggested a capacity for recovery following noise-induced vestibular damage. Human studies have demonstrated that diminished sacculo-collic responses are related to the severity of noise-induced hearing loss, and dose-dependent vestibular deficits following noise exposure have been corroborated in animal models. Further work is needed to better understand the physiological and functional consequences of noise-induced vestibular impairment in animals and humans.

Vestibular consequences of mild traumatic brain injury and blast exposure: a review.

The purpose of this article is to review relevant literature on the effect of mild traumatic brain injury (mTBI) and blast injury on the vestibular system. Dizziness and imbalance are common sequelae associated with mTBI, and in some individuals, these symptoms may last for six months or longer. In war-related injuries, mTBI is often associated with blast exposure. The causes of dizziness or imbalance following mTBI and blast injuries have been linked to white matter abnormalities, diffuse axonal injury in the brain, and central and peripheral vestibular system damage. There is some evidence that the otolith organs may be more vulnerable to damage from blast exposure or mTBI than the horizontal semicircular canals. In addition, benign paroxysmal positional vertigo (BPPV) is a common vestibular disorder following head injury that is treated effectively with canalith repositioning therapy. Treatment for (non-BPPV) mTBI-related vestibular dysfunction has focused on the use of vestibular rehabilitation (VR) augmented with additional rehabilitation methods and medication. New treatment approaches may be necessary for effective otolith organ pathway recovery in addition to traditional VR for horizontal semicircular canal (vestibulo-ocular reflex) recovery.

Characteristics and Treatment Outcomes of Benign Paroxysmal Positional Vertigo in a Cohort of Veterans.

BACKGROUND: The Mountain Home Veterans Affairs (VA) Medical Center has been diagnosing and treating veterans with benign paroxysmal positional vertigo (BPPV) for almost 2 decades. The clinic protocol includes a 2-week follow-up visit to determine the treatment outcome of the canalith repositioning treatment (CRT). To date, the characteristics of BPPV and treatment efficacy have not been reported in a cohort of veterans with BPPV. PURPOSE: To determine the prevalence and characteristics of veterans diagnosed with BPPV in a Veterans Affairs Medical Center Audiology Clinic and to examine treatment outcomes. RESEARCH DESIGN: Retrospective chart review. STUDY SAMPLE: A total of 102 veterans who tested positive for BPPV in the Vestibular Clinic at the Mountain Home VA Medical Center from March 2010 to August 2011. RESULTS: In 102 veterans who were diagnosed with BPPV, the posterior semicircular canal was most often involved (75%), motion-provoked vertigo was the most common symptom (84%), and the majority (43%) were diagnosed with BPPV in their sixth decade. The prevalence of BPPV in the Audiology Vestibular Clinic was 15.6%. Forty-one percent of veterans reported a symptom onset within 12 months of treatment for BPPV; however, 36% reported their symptoms began > 36 months prior to treatment. CRT was effective (negative Dix-Hallpike/roll test) in most veterans (86%) following 1 treatment appointment (M = 1.6), but more than half reported incomplete symptom resolution (residual dizziness) at the follow-up appointment. Eighteen percent of veterans experienced a recurrence (M = 1.8 years; SD = 1.7 years). CONCLUSIONS: The characteristics and treatment outcomes of BPPV in our veteran cohort was similar to what has been reported in the general population. Future work should focus on improving the timeliness of evaluation and treatment of BPPV and examining the time course and management of residual dizziness.

A Benign Paroxysmal Positional Vertigo Triage Clinic.

PURPOSE: The purpose of this study was to evaluate the effectiveness of triaging patients with motion-provoked dizziness into a benign paroxysmal positional vertigo (BPPV) clinic. METHOD: A retrospective chart review was performed of veterans who were tested and treated for BPPV in a triaged BPPV clinic and veterans who were tested and treated for BPPV in a traditional vestibular clinic. RESULTS: The BPPV triage clinic had a hit rate of 39%. On average, the triaged BPPV clinic reduced patient wait times by 23 days relative to the wait times for the traditional vestibular clinic while also reducing patient costs. CONCLUSION: Triaging patients with BPPV is one method to improve access to evaluation and treatment and a mechanism for the effective use of clinic time and resources.

Vestibular, balance, microvascular and white matter neuroimaging characteristics of blast injuries and mild traumatic brain injury: Four case reports.

BACKGROUND: Case reports are presented on four Veterans, aged 29-46 years, who complained of chronic dizziness and/or postural instability following blast exposures. Two of the four individuals were diagnosed with mild traumatic brain injury and three of the four were exposed to multiple blasts. Comprehensive vestibular, balance, gait, audiometry and neuroimaging procedures were used to characterize their injuries. CASE REPORT: Vestibular assessment included videonystagmography, rotary chair and cervical and ocular vestibular evoked myogenic potentials. Balance and gait testing included the sensory organization test, preferred gait speed and the dynamic gait index. Audiometric studies included pure tone audiometry and middle-ear measurements. Neuroimaging procedures included high resolution structural magnetic resonance imaging, susceptibility-weighted imaging and diffusion-tensor imaging. FINDINGS: Based on the neuroimaging and vestibular and balance test results, it was found that all individuals had diffuse axonal injuries and all had one or more micro-hemorrhages or vascular anomalies. Three of the four individuals had abnormal vestibular function, all had abnormally slow walking speeds and two had abnormal gait and balance dysfunction. CONCLUSION: The use of contemporary neuroimaging studies in conjunction with comprehensive vestibular and balance assessment provided a better understanding of the pathophysiology and pathoanatomy of dizziness following blast exposures than standard vestibular and balance testing alone.

The effect of noise exposure on the cervical vestibular evoked myogenic potential.

OBJECTIVE: The purpose of this study was to investigate the effects of noise exposure on the cervical vestibular evoked myogenic potential (cVEMP) in individuals with asymmetric noise-induced sensorineural hearing loss (NIHL). DESIGN: A cross-sectional observational study was used to compare cVEMP characteristics in 43 individuals with a history of noise exposure greater in one ear (e.g., the left ear of a right-handed rifle shooter) and asymmetric sensorineural hearing loss consistent with the history of noise exposure and in 14 age-matched controls. The characteristics of hearing loss were examined further for the noise-exposed participants with abnormal cVEMPs and the noise-exposed participants with normal cVEMPs. RESULTS: Thirty-three percent of the noise-exposed participants had abnormal cVEMPs, whereas cVEMPs were present and symmetrical in 100% of the age-matched controls, and cVEMP threshold was greater in the noise-exposed group than in the control group. Abnormal cVEMPs occurred most often in the ears with poorer hearing (or greater NIHL), and the noise-exposed participants who had abnormal cVEMPs had poorer high-frequency pure-tone thresholds (greater NIHL) and greater interaural high-frequency pure-tone threshold differences than the noise-exposed participants with normal cVEMPs. CONCLUSIONS: These findings are consistent with previous studies that suggest that the sacculocollic pathway may be susceptible to noise-related damage. There is emerging evidence that the severity of NIHL is associated with the presence or absence of cVEMPs.

Normative data for the subjective visual vertical test during centrifugation.

BACKGROUND: The otoliths act as gravito-inertial force sensors and contribute to the perception of spatial orientation. The perception of gravitational vertical can be assessed by asking a subject to adjust a light bar to the vertical. Prior to clinical use of the SVV (subjective visual vertical) test, normative data and test-retest reliability must be established. PURPOSE: To obtain normative data and d etermine the test-retest reliability for the SVV test performed in static and dynamic test conditions. RESEARCH DESIGN: A descriptive design was used to obtain normative data. STUDY SAMPLE: Twenty-four young adults with no history of neurological disease, middle-ear pathology, open or closed head injury, cervical injury, or audiovestibular disorder participated in the study. DATA COLLECTION AND ANALYSIS: The SVV angle was measured in the static position and in three dynamic conditions: (1) on-axis clockwise (CW) rotation, (2) off-axis CW rotation of right ear, and (3) off-axis CW rotation of left ear. RESULTS: In young healthy individuals, the SVV was <2° for static and on-axis rotation, and shifted up to 11° during unilateral centrifugation. Test-retest reliability of the SVV was good for all test conditions. CONCLUSIONS: The normative data obtained in this study may be useful in identifying patients with chronic utricular dysfunction. We recommend the use of difference angles (on-axis SVV - off-axis SVV) to remove baseline bias and decrease the variability of the SVV angles for the off-axis conditions.

Effects of stimulus and recording parameters on the air conduction ocular vestibular evoked myogenic potential.

BACKGROUND: Vestibular evoked myogenic potentials (VEMPs) have been recorded from the sternocleidomastoid muscle (cervical VEMP or cVEMP) and more recently from the eye muscles (ocular VEMP or oVEMP) in response to air conduction and bone conduction stimuli. Both cVEMPs and oVEMPs are mediated by the otoliths and thereby provide diagnostic information that is complementary to videonystagmography and rotational chair tests. In contrast to the air conduction cVEMP, which originates from the saccule/inferior vestibular nerve, recent evidence suggests the possibility that the air conduction oVEMP may be mediated by the utricle/superior vestibular nerve. The oVEMP, therefore, may provide complementary diagnostic information relative to the cVEMP. There are relatively few studies, however, that have quantified the effects of stimulus and recording parameters on the air conduction oVEMP, and there is a paucity of normative data. PURPOSE: To evaluate the effects of several stimulus and recording parameters on the air conduction oVEMP and to establish normative data for clinical use. RESEARCH DESIGN: A prospective repeated measures design was utilized. STUDY SAMPLE: Forty-seven young adults with no history of neurologic disease, hearing loss, middle ear pathology, open or closed head injury, cervical injury, or audiovestibular disorder participated in the study. DATA COLLECTION AND ANALYSIS: The effects of stimulus frequency, stimulus level, gaze elevation, and recording electrode location on the amplitude and latency of the oVEMP for monaural air conduction stimuli were assessed using repeated measures analyses of variance in an initial group of 17 participants. The optimal stimulus and recording parameters obtained in the initial group were used subsequently to obtain oVEMPs from 30 additional participants. RESULTS: The effects of stimulus frequency, stimulus level, gaze elevation, and electrode location on the response prevalence, amplitude, and latency of the oVEMP for monaural air conduction stimuli were significant. The maximum N1-P1 amplitude and response prevalence were obtained for contralateral oVEMPs using a 500 Hz tone burst presented at 125 dB peak SPL during upward gaze at an elevation of 30°. CONCLUSIONS: The optimal stimulus and recording parameters quantified in this study were used to establish normative data that may be useful for the clinical application of the air conduction oVEMP.

Head injury and blast exposure: vestibular consequences.

Young adults are more likely to suffer blast injury and traumatic brain injury (TBI) than other age groups. This article reviews the literature on the vestibular consequences of blast exposure and TBI and concussion. In addition, the vestibular test findings obtained from 31 veterans with a history of blast exposure and/or mild TBI are presented. The authors discuss loss of horizontal semicircular canal function and postural instability related to head injury. Preliminary data suggest the novel theory that otolith organs are uniquely vulnerable to head injury and blast exposure.

The effect of age on the vestibular evoked myogenic potential and sternocleidomastoid muscle tonic electromyogram level.

OBJECTIVE: Cervical vestibular evoked myogenic potentials (cVEMPs) are short-latency electromyogram (EMG) evoked by high-level acoustic stimuli recorded from the activated sternocleidomastoid muscle and used to evaluate otolith organ function. The purpose of this study was to investigate the effects of aging on the cVEMP and on the sternocleidomastoid muscle EMG level. DESIGN: A cross-sectional observational study was used to investigate differences in cVEMP and sternocleidomastoid muscle EMG level in a group of 24 younger and 24 older individuals. cVEMPs were recorded during activation of the sternocleidomastoid muscle at target EMG levels ranging from 0 to 90 µV and during maximum voluntary contraction of the sternocleidomastoid muscle. RESULTS: The sternocleidomastoid muscle EMG amplitude increased as a function of target EMG level for both age groups; however, the mean EMG amplitude was greater for the younger group than the older group, and the variability of EMG amplitude was greater for the older group. The EMG amplitude at maximum voluntary contraction ranged from 88 to 279 µV for the younger subjects and from 32 to 230 µV for the older subjects, and the mean EMG amplitude at maximum voluntary contraction was significantly greater for the younger group than the older group. The cVEMP amplitude increased as a function of EMG target level for each age group. Although cVEMP amplitude increased as a function of target EMG level for both groups, the older group exhibited smaller cVEMP amplitudes, overall, compared with the younger group. To separate the influence of EMG level from aging on cVEMP amplitude, only the responses obtained at the 30 µV target EMG level were considered for the statistical analysis because there was no significant difference in EMG level between groups at the 30 µV target level. The mean cVEMP amplitudes at the 30 µV target level were 101 and 51 µV for the younger and older groups, respectively, and a statistical analysis indicated that cVEMP amplitude for the younger group was significantly greater than the older group. CONCLUSIONS: The findings suggest that the decrement in cVEMP amplitude is related to both age-related changes in the vestibular system and age-related changes in the sternocleidomastoid muscle.

Auditory steady state responses recorded in multitalker babble.

OBJECTIVE: The primary purpose of this investigation was to determine the effect of multitalker babble on ASSRs in adult subjects with normal hearing (NH) and sensorineural hearing loss (HI). The secondary purpose was to investigate the relationships among ASSRs, word recognition in quiet, and word recognition in babble. DESIGN: ASSRs were elicited by a complex mixed-modulation tonal stimulus (carrier frequencies of 500, 1500, 2500, and 4000 Hz; modulation rate of 40 or 90 Hz) presented in quiet and in babble. The level of each carrier frequency was adjusted to match the level of the multitalker babble spectrum, which was based on the long term speech spectrum average. Word recognition in noise (WIN) performance was measured and correlated to ASSR amplitude and ASSR detection rate. STUDY SAMPLE: Nineteen normal-hearing adults and nineteen adults with sensorineural hearing loss were recruited. RESULTS AND CONCLUSIONS: The presence of babble significantly reduced the ASSR detection rate and ASSR amplitude for NH subjects, but had minimal effect on ASSRs for HI subjects. In addition, babble enhanced ASSR amplitude at high stimulus levels. ASSR detection rate and ASSR amplitude recorded in quiet and babble were significantly correlated with word recognition performance for NH and HI subjects.

Monothermal caloric screening test performance: a relative operating characteristic curve analysis.

OBJECTIVE: The objective of the present study was to evaluate the performance of the monothermal caloric screening test in a large sample of patients. DESIGN: A retrospective analysis of the medical records of 1002 consecutive patients who had undergone vestibular assessment at the Mayo Clinic during the years 1989 and 1990 was conducted. Patients with incomplete alternate binaural bithermal (ABB) caloric testing, congenital or periodic alternating nystagmus, or bilateral vestibular loss were excluded from the study. Clinical decision theory analyses (relative operating characteristic curves) were used to determine the accuracy with which the monothermal warm (MWST) and monothermal cool (MCST) caloric screening tests predicted the results of the ABB caloric test. Cumulative distributions were constructed as a function of the cutoff points for monothermal interear difference (IED) to select the cutoff point associated with any combination of true-positive and false-positive rates. RESULTS: Both MWST and MCST performed well above chance level. The test performance for the MWST was significantly better than that of the MCST for three of the four ABB gold standards. A 10% IED cutoff point for the MWST yielded a false-negative rate of either 1% (UW >or=25%) or 3% (UW >or=20%). The use of a 10% IED (UW >or=25%) for the MWST would have resulted in a 40% reduction (N = 294) in the number of ABB caloric tests performed on patients without a unilateral weakness. CONCLUSIONS: The results of this study indicated that the MWST decreases test time without sacrificing the sensitivity of the ABB caloric test.

The influence of voluntary tonic EMG level on the vestibular-evoked myogenic potential.

Vestibular-evoked myogenic potentials (VEMPs) are proposed as a reliable test to supplement the current vestibular test battery by providing diagnostic information about saccular and/or inferior vestibular nerve function. VEMPs are short-latency electromyograms (EMGs) evoked by high-level acoustic stimuli and recorded from surface electrodes over the tonically contracted sternocleidomastoid muscle. VEMP amplitude is influenced by the EMG level, which must be controlled. This study examined the ability of subjects to achieve the EMG target levels over a range of target levels typically used during VEMP recordings. In addition, the influence of target EMG level on the latency and amplitude of the click- and tone-evoked VEMP was examined. The VEMP amplitude increased as a function of EMG target level, and the latency remained constant. EMG target levels ranging from 30 microV to 50 microV are suggested for clinical application of the VEMP.

Predicted gain and functional gain with transcranial routing of signal completely-in-the-canal hearing aids.

Transcranial routing of signal (TCROS) was accomplished using completely-in-the-canal (CIC) hearing aids in 5 profoundly unilaterally hearing-impaired individuals. The functional gain realized by the participants far exceeded the gain predicted by measuring the acoustic output and real ear aided response of the hearing aids. The difference between predicted and functional gain increased with signal frequency and was attributed at least in part to mechanical vibration of the hearing aid in the external canal. Implications for fitting unilateral hearing loss using TCROS amplifying systems are discussed.

The effects of click and tone-burst stimulus parameters on the vestibular evoked myogenic potential (VEMP).

Vestibular evoked myogenic potentials (VEMP) are short latency electromyograms (EMG) evoked by high-level acoustic stimuli and recorded from surface electrodes over the tonically contracted sternocleidomastoid (SCM) muscle and are presumed to originate in the saccule. The present experiments examined the effects of click and tone-burst level and stimulus frequency on the latency, amplitude, and threshold of the VEMP in subjects with normal hearing sensitivity and no history of vestibular disease. VEMPs were recorded in all subjects using 100 dB nHL click stimuli. Most subjects had VEMPs present at 500, 750, and 1000 Hz, and few subjects had VEMPs present at 2000 Hz. The response amplitude of the VEMP increased with click and tone-burst level, whereas VEMP latency was not influenced by the stimulus level. The largest tone-burst-evoked VEMPs and lowest thresholds were obtained at 500 and 750 Hz. VEMP latency was independent of stimulus frequency when tone-burst duration was held constant.

The effects of high-frequency hearing loss on low-frequency components of the click-evoked otoacoustic emission.

Click-evoked otoacoustic emission (CEOAE) input/output (I/O) functions were measured in ears with normal hearing and in ears with sensorineural hearing loss above 2000 Hz. The low- to midfrequency CEOAEs obtained from the ears with high-frequency hearing loss were significantly reduced in level compared to the CEOAEs obtained from the ears with normal hearing even though there were no significant group differences in the 250-2000 Hz pure-tone thresholds. The findings are discussed within the context of two hypotheses that explain the low- to midfrequency reduction in transient-evoked otoacoustic emission (TEOAE) magnitude: (1) subclinical damage to the more apical regions of the cochlea not detected by behavioral audiometry, or (2) trauma to the basal region of the cochlea that affects the generation of low-frequency emissions. It is proposed that localized damage at basal cochlear sites affects the generation of low- to midfrequency CEOAE energy.