Jamie M. Bogle

Vestibular evoked myogenic potentials in patients with vestibular migraine.

Objective Literature investigating otolith reflexes in patients with vestibular migraine (VM) is variable and primarily describes the descending saccular pathway. This research aimed to study ocular vestibular evoked myogenic potential (oVEMP) and cervical vestibular evoked myogenic potential (cVEMP) prevalence and response characteristics in patients with suspected VM and in control patients. The purpose is to assess vulnerabilities within the ascending utricular and descending saccular pathways in the VM population. Study Design Retrospective study Setting Tertiary academic referral center Patients 39 adults with VM, 29 control patients Main Outcome Measure(s) Air conducted oVEMPs and cVEMPs measured with 500 Hz tone burst stimuli Results Age of headache onset was most often in childhood or adolescence, with dizziness onset occurring later. The rate of bilaterally absent oVEMPs was significantly higher (28%, p < 0.01) in the VM group compared with the control group (0%). oVEMP amplitude asymmetry ratios were significantly higher for the definite VM (p < 0.01) and probable VM (p = 0.023) groups than the control group. Eleven patients also had history of concussion; they were significantly more likely to demonstrate bilaterally absent oVEMPs (p < 0.01) in comparison to the control patients. When VM patients with a history of concussion were omitted from analysis, differences in oVEMP amplitude asymmetry (p < 0.01) and bilateral oVEMP absence remained significant (p = 0.015). There were no differences in the rate of bilateral cVEMP presence or response parameters between VM and control groups. Conclusion VEMP presentation differs for some patients diagnosed with VM. The higher rates of abnormal oVEMPs may suggest greater vulnerability within the ascending utricular–ocular pathway in patients with VM.

Dizziness handicap after cartilage cap occlusion for superior semicircular canal dehiscence.

Objective To evaluate the change in self-reported dizziness handicap after surgical repair using the cartilage cap occlusion technique in cases of superior canal dehiscence (SCD). Study Design Repeated measures, retrospective chart review. Setting Tertiary referral center. Patients Twenty patients over a 2-year period who underwent surgical repair of SCD using the cartilage cap occlusion technique. Intervention Therapeutic. Main Outcome Measure Preoperative and postoperative Dizziness Handicap Inventory (DHI) questionnaires were completed (median, interquartile range). Results Preoperative (48, 28–56) and postoperative (33, 19–50) total scores were not significantly different. Scores for patients with moderate/severe preoperative DHI scores (DHI, >30; n = 14) demonstrated significant change (p = 0.001, Wilcoxon paired sample test), whereas those with mild scores did not (DHI, ⩽30; n = 6; p = 0.67). Conclusion Change in DHI score is variable. As described by DHI score, patients with higher preoperative handicap may demonstrate significant improvement after surgery, whereas those with mild handicap may not. These results are similar to previous reports and indicate that the cartilage cap occlusion technique may provide an alternative to middle fossa craniotomy approach for surgical management of symptomatic SCD.

Variability of the modified Balance Error Scoring System at baseline using objective and subjective balance measures

Aim: To investigate preseason modified Balance Error Scoring System (mBESS) performance in a collegiate football cohort; to compare scores to an objective mobile balance measurement tool. Materials & methods: Eighty-two athletes completed simultaneous balance testing using mBESS and the King–Devick Balance Test, an objective balance measurement tool. Errors on mBESS and objective measurements in the double-leg, single-leg (SS) and tandem stances were compared. Results: Mean mBESS error score was 7.23 ± 4.65. The SS accounted for 74% of errors and 21% of athletes demonstrated the maximum error score. There was no significant correlation between mBESS score and objective balance score. Conclusion: The high variability and large number of errors in the SS raises concerns over the utility of the SS in identifying suspected concussion.

The Effect of In-School Saccadic Training on Reading Fluency and Comprehension in First and Second Grade Students: A Randomized Controlled Trial

Efficient eye movements provide a physical foundation for proficient reading skills. We investigated the effect of in-school saccadic training on reading performance. In this cross-over design, study participants (n = 327, 165 males; mean age [SD]: 7 y 6 mo [1y 1 mo]) were randomized into treatment and control groups, who then underwent eighteen 20-minute training sessions over 5 weeks using King-Devick Reading Acceleration Program Software. Pre- and posttreatment reading assessments included fluency, comprehension, and rapid number naming performance. The treatment group had significantly greater improvement than the control group in fluency (6.2% vs 3.6%, P = .0277) and comprehension (7.5% vs 1.5%, P = .0002). The high-needs student group significantly improved in fluency (P < .001) and comprehension (P < .001). We hypothesize these improvements to be attributed to the repetitive practice of reading-related eye movements, shifting visuospatial attention, and visual processing. Consideration should be given to teaching the physical act of reading within the early education curriculum.

Safe use of acoustic vestibular-evoked myogenic potential stimuli: Protocol and patient-specific considerations

Background: Vestibular‐evoked myogenic potentials (VEMPs) are commonly used clinical assessments for patients with complaints of dizziness. However, relatively high air‐conducted stimuli are required to elicit the VEMP, and ultimately may compromise safe noise exposure limits. Recently, research has reported the potential for noise‐induced hearing loss (NIHL) from VEMP stimulus exposure through studies of reduced otoacoustic emission levels after VEMP testing, as well as a recent case study showing permanent sensorineural hearing loss associated with VEMP exposure. Purpose: The purpose of this report is to review the potential for hazardous noise exposure from VEMP stimuli and to suggest clinical parameters for safe VEMP testing. Research Design: Literature review with presentation of clinical guidelines and a clinical tool for estimating noise exposure. Results: The literature surrounding VEMP stimulus‐induced hearing loss is reviewed, including several cases of overexposure. The article then presents a clinical calculation tool for the estimation of a patient’s safe noise exposure from VEMP stimuli, considering stimulus parameters, and includes a discussion of how varying stimulus parameters affect a patient’s noise exposure. Finally, recommendations are provided for recognizing and managing specific patient populations who may be at higher risk for NIHL from VEMP stimulus exposure. A sample protocol is provided that allows for safe noise exposure. Conclusions: VEMP stimuli have the potential to cause NIHL due to high sound exposure levels. However, with proper safety protocols in place, clinicians may reduce or eliminate this risk to their patients. Use of the tools provided, including the noise exposure calculation tool and sample protocols, may help clinicians to understand and ensure safe use of VEMP stimuli.

The effect of repetition rate on air-conducted ocular vestibular evoked myogenic potentials (oVEMPs)

PURPOSE Ocular vestibular evoked myogenic potentials (oVEMPs) are used to describe utricular/superior vestibular nerve function; however, optimal recording parameters have not been fully established. This study investigated the effect of repetition rate on air-conducted oVEMPs. METHOD Ten healthy adults were evaluated using 500-Hz tone bursts (4-ms duration, Blackman gating, 122 dB pSPL). Four repetition rates were used (1.6, 4.8, 8.3, and 26.6 Hz) and resulting oVEMP response presence, amplitude, amplitude asymmetry, and n1/p1 latency were assessed. RESULTS Response presence was significantly reduced for 26.6 Hz using monaural stimulation and for 8.3 Hz and 26.6 Hz for binaural stimulation. For monaural stimulation using 1.6, 4.8, and 8.3 Hz, no significant differences were noted for amplitude or latency. Responses obtained using binaural stimulation demonstrated a significant effect of rate on amplitude, with 8.3 Hz producing significantly reduced amplitude. Binaural amplitudes were significantly larger than monaural contralateral responses but with reduced response presence. No significant differences were noted for latency or amplitude asymmetry. CONCLUSION Using repetition rates of approximately 5 Hz or less may produce more consistent oVEMP response presence with minimal effects on amplitude for monaural or binaural recordings.

Postural orthostatic tachycardia syndrome for the otolaryngologist.

To describe the postural orthostatic tachycardia syndrome (POTS), including clinical presentation, pathophysiology, diagnostic methods, and current management models.

Labyrinthine concussion following gunshot injury: A case report

Objective: Labyrinthine concussion due to a postauricular gunshot wound has not been well reported. Design: Retrospective chart review. Study sample: We describe an otherwise healthy 22-year-old male who received a gunshot wound to the left mastoid and subsequently reported hearing loss and rotational vertigo. Results: Audiometric testing demonstrated significant inverted scoop shaped sensorineural hearing loss. Vestibular diagnostic testing indicated a significant uncompensated left peripheral vestibulopathy. Imaging demonstrated no structural changes to the middle ear or labyrinth, suggesting that the auditory and vestibular losses noted on diagnostic examination were likely due to labyrinthine concussion. Conclusions: Labyrinthine concussion may lead to reduced vestibular reflex pathway following gunshot wounds to the temporal bone. Clinical presentation is likely to vary significantly among cases.