Insight into postural control in unilateral sensorineural hearing loss and vestibular hypofunction.

This pilot study aimed to identify postural strategies in response to sensory perturbations (visual, auditory, somatosensory) in adults with and without sensory loss. We tested people with unilateral peripheral vestibular hypofunction (N = 12, mean age 62 range 23-78), or with Unilateral Sensorineural Hearing Loss (USNHL, N = 9, 48, 22-82), or healthy controls (N = 21, 52, 28-80). Postural sway and head kinematics parameters (Directional Path in the anterior-posterior and medio-lateral directions (sway & head); pitch, yaw and roll (head) were analyzed in response to 2 levels of auditory (none, rhythmic sounds via headphones), visual (static, dynamic) and somatosensory cues (floor, foam) within a simulated, virtual 3-wall display of stars. We found no differences with the rhythmic auditory cues. The effect of foam was magnified in the vestibular group compared with controls for anterior-posterior and medio-lateral postural sway, and all head direction except for medio-lateral. The vestibular group had significantly larger anterior-posterior and medio-lateral postural sway and head movement on the static scene compared with controls. Differences in pitch, yaw and roll emerged between vestibular and controls only with sensory perturbations. The USNHL group did not increase their postural sway and head movement with the increased visual load as much as controls did, particularly when standing on the foam. They did not increase their medio-lateral sway with the foam as much as controls did. These findings suggest that individuals with USNHL employ a compensatory strategy of conscious control of balance, the functional implications of which need to be tested in future research.

Vestibular dysfunction in cochlear implant candidates: Prevalence and outcomes.

PURPOSE: Cochlear implantation (CI) has been shown to reduce vestibular function postoperatively in the implanted ear. The objective of this study was to identify the prevalence of preoperative vestibular weakness in CI candidates and identify any risk factors for postoperative dizziness. STUDY DESIGN: Retrospective cohort study. MATERIALS AND METHODS: Patients who underwent CI and had preoperative videonystagmography (VNG) at the Silverstein Institute from January 1, 2017 to May 31, 2020 were evaluated. The primary endpoint was dizziness lasting more than one month postoperatively. RESULTS: One hundred and forty nine patients were evaluated. Preoperative VNG revealed that 46 (30.9%) had reduced vestibular response (RVR) on one side and 32 (21.5%) had bilateral vestibular hypofunction (BVH). Postoperative dizziness occurred in 14 (9.4%) patients. Patients with postoperative dizziness were more likely to have abnormal preoperative VNG (RVR or BVH), compared to patients without postoperative dizziness (78.6% versus 49.6%, p = 0.0497). In cases of RVR, implantation of the weaker or stronger vestibular ear did not affect the postoperative dizziness (16.1% versus 6.7%, p = 0.38). Postoperative VNG in patients with dizziness showed decreased caloric responses in the implanted ear (28.4 to 6.4 degrees/s, p = 0.02). CONCLUSION: Preoperative caloric weakness is prevalent in CI candidates and abnormal preoperative vestibular testing may be a predictor of postoperative dizziness. CI has the potential to cause vestibular injury and preoperative testing may aid in both counseling and decision-making.

Uso da posturografia para identificação do risco de queda em idosos com tontura / Use of posturography to identify the risk of falling in elderly people with dizziness

RESUMO Objetivo avaliar se a posturografia, exame que avalia a habilidade de manter o equilíbrio em condições sensoriais conflitantes, pode identificar risco de queda em idosos com tontura. Métodos comparar os resultados posturográficos de idosos com e sem história de quedas, pareados por gênero, idade e diagnóstico etiológico da tontura. Resultados dezoito idosos com quedas - 4 com único episódio e 14 com história de 2 ou mais quedas no último ano - foram comparados com 18 idosos sem quedas, pareados por gênero, idade e diagnóstico etiológico. Pacientes com quedas apresentaram resultados piores para as análises de dependência visual (p=0,04, p=0,01, p=0,03). Pacientes com quedas recorrentes (2 ou mais episódios) apresentaram piores resultados em diversas condições sensoriais: somatossensorial, vestibular, dependências visuais e índice de equilíbrio composto. Conclusão a posturografia mostrou-se útil na identificação de idosos com quedas, principalmente em indivíduos com quadros recorrentes.

ABSTRACT Purpose the aim of this study is to determine whether posturography, an exam used to investigate the ability to maintain balance under conflicting sensory conditions, can identify the risk of falls in eldery patients with dizziness. Methods to compare the posturographic results of elderly people with falls vs elderly people with no falls, paired by sex, age and dizziness etiology. Results 18 fallers, and, of these, 14 with two or more falls in the last year were compared with 18 elderly people without falls. Comparing subjects without falls vs subjects with at least one fall in the last year, fallers obtain worse scores in conditions of visual dependence. Comparing non fallers with subjects with two or more falls, people with recurrent falls obtain worse score in several conditions: somatosensorial, vestibular, visual conflict, and in the main measure, the composite score. Conclusion posturography appears to be a useful tool to identify those at high risk of recurrent falls.

A comparison of head movements tests in force plate and accelerometer based posturography in patients with balance problems due to vestibular dysfunction.

This study compares HS posturography on inertial sensors (MediPost) with force platform posturography in patients with unilateral vestibular dysfunction. The study group included 38 patients (age 50.6; SD 11.6) with unilateral vestibular weakness (UV) and 65 healthy volunteers (48.7; SD 11.5). HS tests were performed simultaneously on the force plate and with MediPost sensor attached at L4. Four conditions applied: eyes open/closed, firm/foam. The tests were performed twice, with the head moving at the frequency of 0.3 Hz (HS 0.3) and 0.6 Hz (HS 0.6). Mean sway velocity was significantly lower for MediPost than force plate in 4th condition both in UV and healthy group. For HS 0.3 the differences between devices were marginal; the highest sensitivity (87%) and specificity (95%) were in 4th condition. For HS 0.6 MediPost revealed lower sensitivity than force plate although the surface parameter improved results. MediPost IMU device and force platform posturography revealed a similar ability to differentiate between patients with balance problems in course of vestibular pathology and healthy participants, despite the differences observed between measuring methods. In some tests surface parameter may be more appropriate than sway velocity in improving MediPost sensitivity.

Virtual and augmented reality in the vestibular rehabilitation of peripheral vestibular disorders: systematic review and meta-analysis.

Vestibular rehabilitation therapy is an established treatment for patients with vestibular dysfunction. Virtual reality (VR) and augmented reality (AR) can be utilised in vestibular rehabilitation. Evidence of the efficacy of VR and AR delivered rehabilitation in patients with peripheral vestibular disorders is reviewed. MEDLINE, EMBASE, CENTRAL, CINAHL, PsychInfo, PsychBITE, OTSeeker, Ei Compendex, IEE, Clinical trials.gov and WebofScience databases were searched. Reduction in vestibular dysfunction symptoms 0-3 months post-intervention was the primary outcome. Secondary outcomes included long-term symptom improvement and side effects. Risk of bias assessment and meta analyses were planned. Five studies meeting eligibility criteria were included. Dizziness Handicap Inventory (DHI) scores 0-3 months post-intervention were reported by four studies. Meta-analysis identified a 1.13 (95% CI, - 1.74, - 0.52) standardized mean difference reduction in DHI in VR and AR treated patients compared to controls. Side effects reported by two studies were reduced by week four of VR intervention. Bias assessment identified DHI scores and side effects to be at high risk or of some concern. Adjunct VR interventions reduced patient DHI significantly more than vestibular rehabilitation alone 0-3 months post-intervention in adult patients diagnosed with unilateral vestibular disease. High quality studies are needed.

Transient peripheral vestibular hypofunction measured with vestibular short-latency evoked potentials following noise exposure in rats.

Exposure to 120 dB sound pressure level (SPL) band-limited noise results in delayed onset latency and reduced vestibular short-latency evoked potential (VsEP) responses. These changes are still present 4 wk after noise overstimulation. Noise-induced hearing loss (NIHL) has been shown to vary in extent and duration based on the noise intensity. This study investigated whether noise-induced peripheral vestibular hypofunction (NPVH) would also decrease in extent and/or duration with less intense noise exposure. In the present study, rats were exposed to a less intense noise (110 dB SPL) but for the same duration (6 h) and frequency range (500-4,000 Hz) as used in previous studies. The VsEP was assessed 1, 3, 7, 14, 21, and 28 days after noise exposure. In contrast to 120 dB SPL noise exposure, the 110 dB SPL noise exposures produced smaller deficits in VsEP responses that fully recovered in 62% (13/21) of animals within 1 wk. These findings suggest that NPVH, a loss or attenuation of VsEP responses with a requirement for elevated stimulus intensity to elicit measurable responses, is similar to NIHL, that is, lower sound levels produce a smaller or transient deficit. These results show that it will be important to determine the extent and duration of vestibular hypofunction for different noise exposure conditions and their impact on balance.NEW & NOTEWORTHY This is the first study to show a temporary noise-induced peripheral vestibular hypofunction that recovers following exposure to continuous noise.

Cognitive and Central Vestibular Functions Correlate in People With Multiple Sclerosis.

Background. Cognitive impairment is common, but poorly managed in people with multiple sclerosis (MS). Balance has been correlated with cognition in people with MS, potentially through shared utilization of central sensory integration pathways. Objective. This study characterized the relationship between central vestibular integration and cognition in people with MS through measurement of several clinical vestibular functions requiring central sensory integration and multiple cognitive domains. Methods. Forty people with MS and 20 controls completed a battery of vestibular and cognitive examinations targeting different central vestibular integration measures and different domains of cognition, respectively. Performance on these measures was compared between people with MS and controls, and then correlational analyses were undertaken between the vestibular and cognitive measures in the MS sample. Results. People with MS performed worse than controls on all vestibular and cognitive measures. There were consistent correlations between vestibular and cognitive measures in the MS sample. Factor analysis of vestibular functions yielded a single factor hypothesized to represent central vestibular integration that demonstrated a significant relationship with a composite cognitive measure in people with MS. Discussion. Our results suggest that vestibular and cognitive dysfunction may both arise from central sensory processing pathways in people with MS. This connection could be targeted through vestibular rehabilitation techniques that improve central sensory processing and both balance and cognition in people with MS.

Continuous Head Motion is a Greater Motor Control Challenge than Transient Head Motion in Patients with Loss of Vestibular Function.

Background. The vestibular system is vital for gaze stability via the vestibulo-ocular reflex, which generates compensatory eye motion in the direction opposite to head motion. Consequently, individuals with peripheral vestibular loss demonstrate impaired gaze stability that reduces functional capacity and quality of life. To facilitate patients' compensatory strategies, two classes of gaze stabilization exercises are often prescribed: (i) transient (eg, ballistic) and (ii) continuous. However, the relative benefits of these two classes of exercises are not well understood. Objective. To quantify head motion kinematics in patients with vestibular loss while they performed both classes of exercises. Methods. Using inertial measurement units, head movements of 18 vestibular schwannoma patients were measured before and after surgical deafferentation and compared with age-matched controls. Results. We found that the head movement during both classes of exercises paralleled those of natural head movement recorded during daily activities. However, head movement patterns were more informative for continuous than transient exercises in distinguishing patients from healthy controls. Specifically, we observed coupling between kinematic measures in control subjects that was absent in patients for continuous but not transient head motion exercises. In addition, kinematic measures (eg, cycle duration) were predictive of standard clinical measures for continuous but not transient head motion exercises. Conclusions. Our data suggest that performing continuous head motion is a greater motor control challenge than transient head motion in patients with less reliable vestibular feedback during the sub-acute stage of recovery, which may also prove to be a reliable measure of progression in vestibular rehabilitation protocols.

Customised vestibular rehabilitation with the addition of virtual reality based therapy in the management of persistent postural-perceptual dizziness.

OBJECTIVE: Visual-vestibular mismatch patients experience persistent postural and perceptual dizziness. Previous studies have shown the benefit of vestibular rehabilitation for visual desensitisation using gaze stabilisation exercises and optokinetic stimulation. This study assessed the benefit of customised vestibular rehabilitation with visual desensitisation and virtual reality based therapy rehabilitation in the management of patients with persistent postural-perceptual dizziness. METHODS: This retrospective study included 100 patients with Situational Characteristic Questionnaire scores of more than 0.9. All patients received virtual reality based therapy along with usual vestibular rehabilitation using gaze stabilisation exercises with a plain background followed by graded visual stimulation and optokinetic digital video disc stimulation. Patients' symptoms were assessed before and after vestibular rehabilitation using the Situational Characteristic Questionnaire, Generalised Anxiety Disorder Assessment-7, Nijmegen Questionnaire and Dizziness Handicap Inventory. RESULTS: There were statistically significant improvements in Situational Characteristic Questionnaire scores, Nijmegen Questionnaire scores and Dizziness Handicap Inventory total score. However, there was a statistically insignificant difference in Generalised Anxiety Disorder Assessment-7 scores. There was a significant positive correlation between post-rehabilitation Situational Characteristic Questionnaire scores and other questionnaire results. CONCLUSION: Incorporating virtual reality based therapy with customised vestibular rehabilitation exercises results in significant improvement in persistent postural-perceptual dizziness related symptoms.

Age adjusted normative data for Video Head Impulse Test in healthy subjects.

PURPOSE: This study aims to assess the effect of age in vestibulo-ocular reflex (VOR) gain measured by Video Head Impulse Test (VHIT) and to present normative data of VOR gain, median gain at 40, 60, 80 and 0-100 ms, and gain asymmetry according to decades of life in healthy subjects. MATERIAL AND METHODS: A total of 132 subjects with no previous history of vestibular disorders were enrolled to assess VOR gain by employing VHIT. The test was performed in the X-axis evaluating both horizontal semicircular canals (HSC). The same right-handed operator performed the test in all subjects. RESULTS: The mean VOR gain was higher in the right ear (0.99 ± 0.09) compared to the left ear (0.97 ± 0.08) (p = 0.001). Median gain at 60 ms was 0.92 ± 0.12 in the right HSC and 0.93 ± 0.10 for the left HSC, without significant difference (p = 0.94). A significant decrease of VOR gain occurred with increasing age in the right ear (r = -0.21, p = 0.01). Median gain at 60 ms decreased significantly as age increased in both HSC (right r = -0.17, p = 0.04; left r = -0.23, p = 0.006). No significant differences in VOR gain values were observed when the sample was stratified by age according to the analysis of variance. CONCLUSIONS: A slight but significant decrease in VOR function was observed as age increased for gain and median gain at 60 ms. Larger studies, including patients with central and peripheral vestibular disorders, are needed to assess the clinical implication of this effect when evaluating patients with vestibular disorders.

Instrumented Gait Analysis to Identify Persistent Deficits in Gait Stability in Adults With Chronic Vestibular Loss.

Importance: Regaining the ability to walk safely is a high priority for adults with vestibular loss. Thus, practitioners need comprehensive knowledge of vestibulopathic gait to design, provide, and/or interpret outcomes of interventions. To date, few studies have characterized the effects of vestibular loss on gait. Objectives: To investigate the use of an instrumented 2-minute walk test in adults with vestibular loss, to further characterize vestibulopathic gait, and to assess whether those with chronic vestibular loss have enduring gait deficits. Design, Setting, and Participants: This cross-sectional study, conducted between April 3, 2018, and June 27, 2019, recruited adults 20 to 79 years of age from an academic, tertiary, hospital-based, ambulatory care setting who were healthy or had confirmed unilateral or bilateral vestibular hypofunction. Of the 43 adults who were screened from convenience and referred samples, 2 declined, and 7 were excluded because of health conditions. Exposures: The main exposure was the instrumented 2-minute walk test, which was conducted with participants using wearable inertial measurement units while they walked a 10-m path at their self-selected speed and turned 180° in their self-selected direction at either end. Main Outcomes and Measures: The primary measures were spatiotemporal gait metrics (eg, stride length [SL] and peak whole-body turning velocity). Multivariate analysis of variance was used to assess between-group differences. Validity was assessed using the area under the curve from receiver operator characteristic analyses. Results: Data from 17 healthy adults (mean [SD] age, 39.27 [11.20] years; 13 [76%] female) and 13 adults with vestibular loss (mean [SD] age, 60.50 [10.81] years; 6 [46%] female) were analyzed. Very large between-group differences were found for SL (left) (estimated marginal mean [SE] for healthy vs vestibular groups, 1.47 [0.04] m vs 1.31 [0.04] m; Cohen d, 1.35; 95% CI, 0.18-2.52), SL (right) (estimated marginal mean [SE] for healthy vs vestibular groups, 1.46 [0.04] m vs 1.29 [0.04] m; Cohen d, 1.44; 95% CI, 0.25-2.62), and peak turn velocity (estimated marginal mean [SE] for healthy vs vestibular groups, 240.17 [12.78]°/s vs 189.74 [14.70]°/s; Cohen d, 1.23; 95% CI, 0.07-2.40). The area under the curve was 0.79 (95% CI, 0.62-0.95) for SL (left), 0.81 (95% CI, 0.64-0.97) for SL (right), and 0.86 (95% CI, 0.72-0.99) for peak turn velocity. Conclusions and Relevance: In this cross-sectional study, instrumented gait analysis had good discriminative validity and revealed persistent deficits in gait stability in those with chronic vestibular loss. The findings of this study suggest that these clinically and functionally meaningful deficits could be targets for vestibular rehabilitation.

Sleep Performance and Chronotype Behavior in Unilateral Vestibular Hypofunction.

OBJECTIVE: To evaluate sleep behavior and its relation to otoneurological parameters in a group of patients with chronic unilateral vestibular hypofunction (UVH) without self-reported sleep disturbances when compared with healthy subjects serving as a control group (CG). METHODS: Fifty-one patients affected by UVH underwent a retrospective clinical and instrumental otoneurological examination, a 1-week actigraphy sleep analysis, and a series of self-report and performance measures (SRM/PM). A CG of 60 gender- and age-matched healthy subjects was also enrolled. A between-group analysis of variance was performed for each variable, while correlation analysis was performed in UVH patients between otoneurological, SRM/PM, and actigraphy measure scores. RESULTS: When compared with CG subjects, UVH patients were found to be spending less time sleeping and taking more time to go from being fully awake to asleep, based on actigraphy-based sleep analysis. Also, SRM/PM depicted UVH patients to have poor sleep quality and to be more prone to an evening-type behavior. Correlations were found between vestibular-related functionality indexes and subjective sleep quality, as well as between longer disease duration and reduced sleep time. CONCLUSION: For the first time, a multiparametric sleep analysis was performed on a large population-based sample of chronic UVH patients. While a different pattern in sleep behavior was found, the cause is still unclear. Further research is needed to expand the extent of knowledge about sleep disruption in vestibular disorders. LEVEL OF EVIDENCE: 3 Laryngoscope, 131:2341-2347, 2021.

Stroke Prediction Based on the Spontaneous Nystagmus Suppression Test in Dizzy Patients: A Diagnostic Accuracy Study.

OBJECTIVE: Failure of fixation suppression of spontaneous nystagmus is sometimes seen in patients with vestibular strokes involving the cerebellum or brainstem; however, the accuracy of this test for the discrimination between peripheral and central causes in patients with an acute vestibular syndrome (AVS) is unknown. METHODS: Patients with AVS were screened and recruited (convenience sample) as part of a prospective cross-sectional study in the emergency department between 2015 and 2020. All patients received neuroimaging, which served as a reference standard. We recorded fixation suppression with video-oculography (VOG) for forward, right, and left gaze. The ocular fixation index (OFI) and the spontaneous nystagmus slow velocity reduction was calculated. RESULTS: We screened 1,646 patients reporting dizziness in the emergency department and tested for spontaneous nystagmus in 148 patients with AVS. We analyzed 56 patients with a diagnosed acute unilateral vestibulopathy (vestibular neuritis) and 28 patients with a confirmed stroke. There was a complete nystagmus fixation suppression in 49.5% of patients with AVS, in 40% of patients with vestibular neuritis, and in 62.5% of patients with vestibular strokes. OFI scores had no predictive value for detecting strokes; however, a nystagmus reduction of less than 2 °/s showed a high accuracy of 76.9% (confidence interval 0.59-0.89) with a sensitivity of 62.2% and specificity of 84.8% in detecting strokes. CONCLUSIONS: The presence of fixation suppression does not rule out a central lesion. The magnitude of suppression was lower compared to patients with vestibular neuritis. The nystagmus suppression test predicts vestibular strokes accurately provided that eye movements are recorded with VOG. CLASSIFICATION OF EVIDENCE: This study provides Class II evidence that in patients with an AVS, decreased fixation suppression recorded with VOG occurred more often in stroke (76.9%) than in vestibular neuritis (37.8%).

Estimated Vestibulogram (EVEST) for Effective Vestibular Assessment.

BACKGROUND: The availability and development of methods testing the vestibuloocular reflex (VOR) brought a broader view into the lateral semicircular canal (L-SCC) function. However, the higher number of evaluated parameters makes more difficult the specialist's diagnose-making process. PURPOSE: To provide medical specialists, a new diagnostic-graphic tool, Estimated Vestibulogram- EVEST, enabling a quick and easy-to-read visualization and comparison of the VOR test results within the L-SCC. METHODS: The development of EVEST involved 148 participants, including 49 healthy volunteers (28 female and 21 male) and 99 (58 female and 41 male) patients affected by different degrees of peripheral vestibular deficit. The corresponding L-SCC VOR test results, from patients meeting the diagnostic criteria, were used to create the EVEST. RESULTS: Based on the test results, we depicted and calculated the EVEST vestibular function asymmetry (VFA) in all the groups. To assess a feasibility of EVEST to describe a vestibular function deficit, we calculated sensitivity and specificity of VFA using a receiver operating characteristic curve (ROC) and compared it to single tests. In all the tests, we determined the cutoff value as the point with the highest sensitivity and specificity. For discrimination of any vestibular deficit, the VFA with cutoff 6.5% was more sensitive (91%) and specific (98%) than single tests. Results showed that EVEST is a beneficial graphic tool for quick multifrequency comparison and diagnosis of different types of the peripheral vestibular loss. CONCLUSIONS: EVEST can help to easily evaluate various types of peripheral vestibular lesion.

Evaluation of the Video Ocular Counter-Roll (vOCR) as a New Clinical Test of Otolith Function in Peripheral Vestibulopathy.

Importance: Video-oculography (VOG) goggles have been integrated into the assessment of semicircular canal function in patients with vestibular disorders. However, a similar bedside VOG method for testing otolith function is lacking. Objective: To evaluate the use of VOG-based measurement of ocular counter-roll (vOCR) as a clinical test of otolith function. Design, Setting, and Participants: A case-control study was conducted to compare vOCR measurement among patients at various stages of unilateral loss of vestibular function with healthy controls. The receiver operating characteristic curve method was used to determine the diagnostic accuracy of the vOCR test in detecting loss of otolith function. Participants were recruited at a tertiary center including the Johns Hopkins outpatient clinic and Johns Hopkins Hospital, Baltimore, Maryland. Participants included 56 individuals with acute (≤4 weeks after surgery), subacute (4 weeks-6 months after surgery), and chronic (>6 months after surgery) unilateral vestibular loss as well as healthy controls. A simple bedside maneuver with en bloc, 30° lateral tilt of the head and trunk was used for vOCR measurement. The study was conducted from February 2, 2017, to March 10, 2019. Intervention: In each participant vOCR was measured during static tilts of the head and trunk en bloc. Main Outcomes and Measures: The vOCR measurements and diagnostic accuracy of vOCR in detecting patients with loss of vestibular function from healthy controls. Results: Of the 56 participants, 28 (50.0%) were men; mean (SD) age was 53.5 (11.4) years. The mean (SD) time of acute unilateral vestibular loss was 9 (7) days (range, 2-17 days) in the acute group, 61 (39) days (range, 28-172 days) in the subacute group, and 985 (1066) days (range 185-4200 days) in the chronic group. The vOCR test showed reduction on the side of vestibular loss, and the deficit was greater in patients with acute and subacute vestibular loss than in patients with chronic loss and healthy controls (acute vs chronic: -1.81°; 95% CI, -3.45° to -0.17°; acute vs control: -3.18°; 95% CI, -4.83° to -1.54°; subacute vs chronic: -0.63°; 95% CI, -2.28° to 1.01°; subacute vs control: -2.01°; 95% CI, -3.65° to -0.36°; acute vs subacute: -1.17°; 95% CI, -2.88° to 0.52°; and chronic vs control: -1.37°; 95% CI, -2.96° to 0.21°). The asymmetry in vOCR between the side of vestibular loss and healthy side was significantly higher in patients with acute vs chronic loss (0.28; 95% CI, 0.06-0.51). Overall, the performance of the vOCR test in discriminating between patients with vestibular loss and healthy controls was 0.83 (area under the receiver operating characteristic curve). The best vOCR threshold to detect vestibular loss at the 30° tilt was 4.5°, with a sensitivity of 80% (95% CI, 0.62%-0.88%) and specificity of 82% (95% CI, 0.57%-1.00%). Conclusions and Relevance: The findings of this case-control study suggest that the vOCR test can be performed with a simple bedside maneuver and may be used to detect or track loss of otolith function.

Characteristics of Benign Paroxysmal Positional Vertigo Following an Earthquake.

INTRODUCTION: Benign Paroxysmal Positional Vertigo (BPPV) is a commonly encountered peripheral vestibular disorder. People exposed to massive earthquakes experience intense and long-term problem associated with dizziness. The purpose of our study is to investigate this relationship and to demonstrate the efficacy of the treatment modalities used in the management of patients with post-earthquake dizziness. METHODOLOGY: The study was carried out by examining the retrospective records of patients who presented with dizziness to the otorhinolaryngological outpatient unit before and after the Elazig earthquake that occurred on 24th Jan 2020. Parameters evaluated include patients' age and gender, onset of dizziness, accompanying symptoms and comorbidities, videonystagmography (VNG) findings, pre- and post-treatment Visual Analogue Scale (VAS), Dizziness Handicap Inventory (DHI), and Hospital Anxiety and Depression Scale (HADS). RESULTS: The number of patients who presented with dizziness to our outpatient clinic after the earthquake and were included in our study totaled 84. The number of patients who visited the outpatient clinic before the earthquake was identified to be 75. In the earthquake related group, while there was a statistically significant difference between residual symptoms (RS) and the need for repetitive repositioning maneuvers, there was no statistically significant difference detected for age, gender, and comorbidities. Also, no statistically significant difference was found in the pre- and post-treatment assessments of VAS, DHI, and HADS median values in the earthquake group. CONCLUSION: There was a remarkable increase in the number of patients presenting with dizziness in the early post-earthquake period. Management of these patients may differ from the classic BPPV. Residual symptoms appearing after performing repositioning maneuvers can be more commonly seen among these patients.

The Instrumented Timed "Up & Go" Test Distinguishes Turning Characteristics in Vestibular Hypofunction.

OBJECTIVE: Deficits in vestibular function increase the risk for falls while turning. However, the clinical assessment of turning in patients with vestibular dysfunction is lacking, and evidence is limited that identifies the effectiveness of vestibular physical therapy in improving turning performance. The purpose of this study was to quantify walking and turning performance during the instrumented Timed "Up & Go" (TUG) test using body-worn inertial measurement units (IMUs). Novel instrumented TUG parameters were investigated for ability to distinguish patients with unilateral vestibular deafferentation (UVD) from control groups and discriminate the differences in turning parameters of patients with UVD following vestibular physical therapy. METHODS: Thirty-eight individuals were recruited following UVD surgery: 26 age-matched veteran controls with reports of dizziness not from a peripheral vestibular origin, and 12 age-matched healthy controls. Participants were donned with IMUs and given verbal instructions to complete the TUG test as fast as safely possible. The IMU-instrumented and automated assessment of the TUG test provided component-based TUG parameters, including the novel walk:turn ratio. Among the participants with UVD, 19 completed an additional instrumented TUG testing after vestibular physical therapy. RESULTS: The walk:turn time ratio showed that turning performance in patients with UVD before rehabilitation is significantly more impaired than both the individuals with nonperipheral conditions and healthy controls. Vestibular rehabilitation significantly improved turning performance and "normalized" their walk:turn time ratio compared with healthy controls. The duration of the straight walking component in individuals with UVD before vestibular physical therapy, however, was not significantly different compared with that component in people after vestibular physical therapy and in healthy controls. CONCLUSION: The IMU-instrumented TUG test can be used to distinguish individuals with vestibular deafferentation and to objectively quantify the change in their turning performance after vestibular physical therapy. IMPACT: The IMU-based instrumented TUG parameters have the potential to quantify the efficacy of vestibular physical therapy and be adopted in the clinic.

Comparison of Activity-Based Home Program and Cawthorne-Cooksey Exercises in Patients With Chronic Unilateral Peripheral Vestibular Disorders.

OBJECTIVE: This study aimed to investigate the effects of an activity-based home program and an exercise-based home program on dizziness severity, balance, and independent level of daily life activities in patients with dizziness due to chronic unilateral peripheral vestibular disorders. DESIGN: A single-blind randomized controlled trial. SETTING: University dizziness management clinics. PARTICIPANTS: Individuals (N=75) between 18 and 65 years of age who had chronic unilateral peripheric vestibular disorders and vestibular rehabilitation indication. INTERVENTION: Participants were randomly divided into 3 groups: an activity-based home program (group 1/activity group), an exercise-based home program (group 2/exercise group), and a control group (group 3). After an initial assessment, all groups participated in the patient education program. In addition, the activity-based home program was administered to the first group, while the Cawthorne-Cooksey home exercise program was administered to the second group. MAIN OUTCOME MEASURES: Visual analog scale (VAS), Vestibular Disorders Activities of Daily Living Scale (VADL), and computerized dynamic posturography before and immediately after the treatment program. RESULTS: A statistically significant improvement was found in the activity and exercise groups in terms of VAS, VADL, Sensory Organization Test (SOT) 5, SOT 6, and SOT (composite) scores compared with the control group (P<.05). A statistically significant improvement was found in the activity group in terms of the instrumental subscale of VADL, SOT 5, SOT 6, and SOT (composite) scores compared with the exercise group. CONCLUSIONS: The activity-based home program was more effective in improving the home management task, the occupational task, and balance than the exercise-based home treatment program in patients with chronic peripheral vestibular disorders.

Vestibular involvement of PFAPA syndrome.

OBJECTIVE: PFAPA syndrome is derived from the initials of the English words of the findings that make up the syndrome ("Periodic Fever", "Aphthous Stomatitis", "Pharyngitis", "Adenitis"). This study aims to evaluate the vestibular system in patients with PFAPA syndrome by the cVEMP test and to give a general review of PFAPA syndrome in light of current literature. METHODS: In this prospective study, 30 patients aged 4-6 who were diagnosed with PFAPA in a tertiary pediatrics clinic, between January 2016 and February 2020 and 30 children of the same age group who applied to a tertiary otorhinolaryngology clinic for other reasons and proven to have no hearing or vestibular problems were included and in addition to routine physical examination, electromyographic activity of the sternocleidomastoid muscle surface was measured. RESULTS: We found that the amplitude difference between cVEMP p1-n1 in patients with PFAPA syndrome in both ears decreased compared to the healthy control group. CONCLUSION: Our study proves there is a vestibular system involvement of PFAPA syndrome. This study is the first in the literature to search the relationship between PFAPA and the vestibular system.

Effects of using cane and vestibular rehabilitation on the walking function in elderly patients with dizziness.

OBJECTIVE: Adults over the age of 65 years with balance disorders are at about twice the risk of falls, compared with those without balance disorders. Falls contribute to about 74% of the proximal femoral fractures commonly seen in the elderly. Since balance disorders are more prevalent in older adults than in younger adults, it is important to deal with balance disorders in older adults to prevent falls and the resulting deterioration in their ADL (activity of daily living). In this study, we investigated the effects of vestibular rehabilitation (VR) and cane use on improving gait and balance in patients aged over 65 years with balance disorder. METHODS: Patients aged over 65 years presenting to the Department of Otolaryngology at St. Marianna University School of Medicine between July 1 and November 1, 2018, with symptoms of dizziness for ≥ 3 months and a Japanese translation of the Dizziness Handicap Inventory score of ≥ 26 were included in the study. We quantitatively analyzed their gait before and after VR, and with and without the use of a cane. RESULTS: A total of 21 patients participated in the study (14 women; mean age 73.9 ± 6.9 years). Before VR, using a cane made no difference to step length or walking speed. After VR, using a cane increased step length from 50.5 cm (95% confidence interval [CI], 47.4-53.7 cm) to 52.0 cm (95% CI, 48.9-55.1 cm) (p = 0.039). There was no change in walking speed. A comparison of walking assessment results while using a cane before and after VR showed that step length increased from 49.9 cm (95% CI, 46.6-53.2 cm) to 52.0 cm (95% CI, 48.9-55.1 cm) (p = 0.005), and walking speed increased from 90.5 cm/s (95% CI, 82.7-98.4 cm/s) to 96.1 cm/s (95% CI, 88.3-103.9 cm/s) (p = 0.005). CONCLUSIONS: Walking speed and step length with the use of a cane significantly improved following VR. VR and cane use may act synergistically to improve walking.