Naoki Saka

Detection of utricular dysfunction using ocular vestibular evoked myogenic potential in patients with benign paroxysmal positional vertigo

BACKGROUND The ocular vestibular evoked myogenic potential (oVEMP) is thought to originate from the contralateral utricular organ. However, the clinical use of oVEMP has not yet been established. This study aimed to clarify whether oVEMP could be used to detect utricular dysfunction in patients with benign paroxysmal positional vertigo (BPPV). MATERIALS AND METHODS Sixteen patients with BPPV underwent oVEMP measurements. Recordings were made on 2 separate occasions: when typical nystagmus was confirmed (pretreatment oVEMP) and 1 week after performing Epleys maneuver (posttreatment oVEMP). Results were evaluated using the asymmetry ratio (AR) of n1-p1 wave peak-to-peak amplitude and defined as reduced oVEMP when AR was >31.6%, or augmented oVEMP when AR was <-31.6%. RESULTS Bilateral responses were recorded in 13 patients on the pretreatment oVEMP. Abnormal results were found in 11 patients (84.5%). These included 5 patients with reduced response and 6 with augmented response. On the posttreatment oVEMP, abnormal results were found in 5 patients (38.5%). All indicated reduced oVEMP. Abnormal results on the pretreatment oVEMP were not related to any persistent positional vertigo (p>0.05, Fishers exact test). Three out of 4 patients (75.0%) with continuing unsteadiness had abnormal results (reduced response) on the posttreatment oVEMP. DISCUSSION The oVEMP measurements indicated abnormal function of the utricle in patients with BPPV. Reduced oVEMP is thought to originate from the partial degeneration of utricular hair cells. Conversely, augmented oVEMP in the affected ear is thought to originate from a hypermobility of the stereocilia due to the detachment of otoconia within the utricle. The above-mentioned utricular dysfunction should be independent of the existence of otoconia in the semicircular canal; thus, the results of oVEMP were not related to the recovery of symptoms. CONCLUSION oVEMP can be reliably used to detect utricular lesions in patients with BPPV.

Vestibular evoked myogenic potential induced by bone-conducted stimuli in patients with conductive hearing loss

Conclusions. Bone-conducted vestibular evoked myogenic potentials (B-VEMPs) showed high specificity for the presence of vertigo in patients with unilateral chronic otitis media (COM). These results suggest that vestibular function can be evaluated with B-VEMPs, even in patients with conductive hearing loss. Objective. The purpose of this study was to investigate the VEMPs induced by bone-conducted stimuli (B-VEMPs) in patients with conductive hearing loss due to perforated COM. Subjects and methods. The subjects were 48 patients with unilateral perforated COM and conductive hearing loss. The disequilibrium group consisted of 25 patients, and the non-disequilibrium group consisted of 23 patients. The control group comprised 35 healthy volunteers. B-VEMPs were stimulated with tone burst sound of 60 dB nHL and 250 Hz delivered from a bone vibrator and were recorded for each subject. The results of B-VEMP were compared between disequilibrium and non-disequilibrium groups. Results. The mean interaural ratio was 16.5±12.1% in the control group, thus the normal range was <40.7%. Abnormal results were not found in any subject in the non-disequilibrium group but were found in 13 patients (54.0%) in the disequilibrium group (p<0.001). The ear with COM showed lower responses than the intact ear in all subjects with abnormal results.

Immediate efficacy of the canalith repositioning procedure for the treatment of benign paroxysmal positional vertigo.

Objective: To study the immediate efficacy of the canalith repositioning procedure (CRP) in the treatment of benign paroxysmal positional vertigo. Patients: Thirty-four patients with benign paroxysmal positional vertigo. Intervention: Eighteen patients were treated with CRP (CRP group); 16 control patients did not receive CRP treatment (non-CRP group). Main Outcome Measures We compared the success rates of the CRP and non-CRP groups. The treatment was considered successful if it prevented vertigo and dizziness. Patients were evaluated 3 times: immediately posttreatment (the day after the first visit), in the short term (1 wk after treatment), and in the midterm (1 mo after treatment) Results: Successful outcomes occurred in 12 patients (67%) from the CRP group and in 1 patient (6%) from the non-CRP group as immediate results (p < 0.001), 13 (72%) and 4 patients (25%) in the short term, respectively, (p = 0.007), and 16 (89%) and 14 patients (88%) in the midterm, respectively, (p > 0.05). Among patients in the CRP group who did not report immediate success, 1 patient (6%) reported success after 1 week (short term), and 4 patients (67%) had successful outcomes after 1 month (midterm). Conclusion: The immediate efficacy of CRP supported the canalolithiasis theory. The prognosis of patients with immediate unsuccessful results with CRP was somewhat worse than that for patients without CRP treatment.

Analysis of benign paroxysmal positional nystagmus in children.

INTRODUCTION Benign paroxysmal positional vertigo (BPPV) is the most common vestibular disorder. However, BPPV in children has been studied less extensively than in the adult population. This is because the observation of benign paroxysmal positional nystagmus (BPPN) in children is technically very difficult and BPPV is rare in children. In this study, we present the only two cases of BPPV in children in which we successfully recorded and analyzed the BPPN. METHODS One case was an 11-year-old boy and the other was a 3-year-old girl. We analyzed their BPPN three-dimensionally. RESULTS Apogeotropic positional nystagmus was observed in the first case. We analyzed it to verify the presence of cupulolithiasis in the horizontal semicircular canal (HSCC). Geotropic positional nystagmus was observed in the second case, and the analyzed data indicated the presence of canalolithiasis in HSCC. Over the last decade, we have examined 3341 patients complaining of vertigo or dizziness. Among them, there were 63 children with the same complaint, so that the proportion of cases of BPPV in children was only 3% (2/63). DISCUSSION Among patients complaining of vertigo or dizziness, children with BPPV are rare (3%). However, we have recorded their BPPN to confirm that BPPV does occur in children and that their characteristics of positional nystagmus are generally identical to those in adults. We emphasize that this is the first report of a child as young as 3 years old being diagnosed with BPPV.

A case of Churg-Strauss syndrome with refractory otitis media.

OBJECTIVE Churg-Strauss syndrome (CSS) is known as autoimmune vasculitis with peripheral eosinophilia after bronchial asthma and rarely has otological findings. We present a case of CSS with refractory otitis media and discuss the relationship between otological symptoms of CSS and eosinophilic otitis media. CASE REPORT A 60-year-old woman had suffered from recurrent sinusitis for 8 years, and also otitis media with effusion for 4 months. Eruption with peripheral eosinophilia was found in the lower legs; therefore, she was diagnosed with CSS. She was treated with systemic administration of prednisolone, intratympanic injection of betamethasone, and betamethasone nasal spray; thereafter, eosinophilia, otitis media and sinusitis rapidly improved. CONCLUSION The features of eosinophilic otitis media are similar to the otological symptoms of CSS. It should be considered whether patients with eosinophilic otitis media have early phase CSS.

Hearing and vestibular functions after plugging surgery for the posterior semicircular canal

Conclusions. Results of audiometry, caloric testing and vestibular evoked myogenic potential (VEMP) testing were hardly influenced by plugging surgery. Objective. To evaluate the influence of surgical plugging of the posterior semicircular canal on inner ear function in patients with benign paroxysmal positional vertigo (BPPV). Subjects and methods. The subjects were five consecutive patients with intractable BPPV who underwent plugging surgery. The following functions of the inner ear were examined before and 6 months after surgery. Cochlea function was evaluated by the average hearing level of three frequencies (500, 1000 and 2000 Hz), that of the semicircular canal by canal paresis percent (CP%) in caloric testing and that of the otolith by the left–right difference ratio on VEMP testing. Results. Positional vertigo was resolved in all patients. One subject was completely deaf before and after surgery. The average hearing level did not change more than 10 dB after surgery in the other four cases. CP% did not worsen more than 10% in any case. The VEMP results after surgery did not change more than 10% from before surgery in any case.

Furosemide-loading vestibular evoked myogenic potential testing can suggest developing bilateral involvement of unilateral Meniere's disease

Abstract Conclusions: Patients with positive results of furosemide-loading vestibular evoked myogenic potential (F-VEMP) testing in the unaffected ears of unilateral Menieres disease have a high incidence of developing bilateral lesions. Objective: To clarify the meaning of positive results of F-VEMP testing of the unaffected ear of patients with unilateral Menieres disease. Methods: Twenty-five patients with unilateral Menieres disease were investigated in this study. The positive group consisted of 6 patients with positive results of F-VEMP testing in the contralateral ear and the negative group consisted of 19 patients with negative results. The incidence of contralateral involvement was compared in both groups by the Kaplan–Meier method. Results: Contralateral involvement was seen in three cases (50%) in the positive group after 2, 12, and 26 months and in three cases (16%) in the negative group after 27, 56, and 78 months. The positive group had a higher incidence of contralateral involvement than the negative group (p = 0.0017, according to a log-rank test).

Is a pulling sensation in the anteroposterior direction associated with otolith dysfunction

Abstract Conclusion: A pulling sensation in the anteroposterior direction is suggested to originate from a dysfunction of the otolith organs. Objectives: Previous study with vestibular evoked myogenic potential (VEMP) confirmed that a falling sensation (in an up or down direction) and a lateral tilt sensation (in a right or left direction) were caused by otolith lesions. The purpose of this study was to clarify whether a pulling sensation in the anteroposterior (forward or backward) direction originates from otolith dysfunction. Methods: The otolith function was assessed by cervical and ocular VEMPs (cVEMPs and oVEMPs) in 12 patients who complained of a forward or backward pulling sensation. cVEMPs were evaluated by the asymmetry ratio (AR) of the amplitude of the p13-n23 wave and the peak latencies of the p13 and n23 waves. oVEMPs were evaluated by the AR of the amplitude of the n1-p1 wave and the peak latency of the n1 and p1 waves. Results: Abnormal ARs on cVEMP were observed in 7 of 12 patients. Nine of 12 patients had abnormal oVEMP results including 3 bilateral absent responses. Most (10 of 12) patients had abnormal cVEMP and/or oVEMP results. The latency of each detected wave was within the normal ranges.

Vestibular-evoked myogenic potential in response to bone-conducted sound in patients with otosclerosis.

Abstract Conclusion: Saccular dysfunction is a major cause of balance problems in patients with otosclerosis. Vestibular-evoked myogenic potential in response to bone-conducted sound (BC-VEMP) testing is useful for diagnosis of these patients. Objectives: The purpose of this study was to elucidate the origin of balance problems in patients with otosclerosis using BC-VEMP. Methods: Subjects comprised 25 patients with unoperated otosclerosis (9 men and 16 women). They were divided into two groups depending on type of balance problems. Results of cochleo-vestibular functions including pure-tone audiometry, caloric testing, and BC-VEMP testing were compared between the two groups. Results: Ten patients had complained of dizziness and/or vertigo (disequilibrium group), and the other 15 patients had not (Non-disequilibrium group). Nine patients showed abnormal results on BC-VEMP testing in the disequilibrium group, while one patient had abnormal results in the non-disequilibrium group (p < 0.001).

Omissions of medical fees covered by health insurance for outpatients in our department

Economic efficiency has recently been required even in public hospitals. Medical fees from health insurance account for most of the medical income of our hospital. Medical fees were counted in units of points, with one point equaling 10yen. However, it is unclear how many points are omitted in determining medical fees to be paid by health insurance. This study investigated the extent of such omissions.The subjects were all outpatients who consulted the Department of Otolaryngology of Takarazuka Municipal Hospital between January 24 and 28, 2005. Following the completion of daily work, we examined the slip sheets actually used to calculate payments and determined the omissions. In our department, when a doctor completes the treatment and/or examination, the nurse checks the appropriate items in slip sheets.Omissions were found on slip sheets for 40 of 372 patients (10.8%). Based on the total reward receipts (322, 988 points), 5298 points (1.6%) had been omitted. Omissions for balance tests, middle ear fiberscopy and laryngoscopy were particularly common.The loss associated with this were estimated as about 2, 360, 000yen annually. The reason for omissions appeared to be the lack of presence of a nurse during treatment and/or examinations and poor knowledge of nurses about otolaryngological care.