Research in Vestibular Science

Review

Canal Conversion and Reentry of Otolith in Benign Paroxysmal Positional Vertigo: Jong Sei Kim, Minbum Kim; Res Vestib Sci. 2023;22(3):59-67. Published online September 15, 2023; DOI: https://doi.org/10.21790/rvs.2023.22.3.59

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Abstract PDF: During the treatment process for benign paroxysmal positional vertigo (BPPV) using the canalith repositioning procedure, the otolith can inadvertently enter the semicircular canal instead of the utricle. Canal conversion refers to the situation where the otolith enters a different semicircular canal, while reentry occurs when the otolith returns to the same semicircular canal. The occurrence of a canal conversion can complicate the accurate diagnosis and treatment of BPPV, potentially leading to misdiagnosis and unsuccessful results in the canalith repositioning procedure. In this review, we aim to summarize the incidence, clinical features, and associated risk factors of canal conversion and reentries.

Original Article

Influence of Otoliths on the Vestibulo-Ocular Reflex in Horizontal Canal Benign Paroxysmal Positional Vertigo: Hee Soo Yoon, Jae Yeong Jeong, Jae Ho Chung, Ha Young Byun, Chul Won Park, Seung Hwan Lee; Res Vestib Sci. 2020;19(2):49-54. Published online June 15, 2020; DOI: https://doi.org/10.21790/rvs.2020.19.2.49

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Abstract PDF: Objectives
The aim of the study was to evaluate the possible alteration of the vestibulo-ocular reflex (VOR) in patients with horizontal canal benign paroxysmal positional vertigo (h-BPPV) using the video head impulse test (vHIT).
Methods
This was a prospective case-control study of BPPV patients. We includeed 133 patients with h-BPPV who underwent the vHIT prior to the positioning test. The control group consisted of 76 normal subjects who also underwent the vHIT. The vHIT parameters of gain and asymmetry were assessed, and clinical parameters such as treatment duration, number of canalith reposition maneuvers executed and recurrence rates were evaluated. The VOR and clinical parameters were compared between the h-BPPV and control group. The VOR parameters of h-BPPV canalolithiasis were also compared with those of cupulolithiasis.
Results
The mean age of the patients was 56.5 years and the male to female ratio was 1:2.02. Of the patients, 75 were diagnosed as having the canalolithiasis type of h-BPPV, while the other 58 had the cupulolithiasis type. The mean vHIT gains of the ipsi-lesional horizontal canal plane were 1.13 and 1.15 in the h-BPPV and control group, respectively (p=0.564). However, the asymmetry of the VOR was significantly higher in the h-BPPV than the control group (p=0.013), while the gains and asymmetries of the vHIT in the canalolith and cupulolith types were not significantly different (p=0.454, p=0.826).
Conclusions
The asymmetry of VOR is significantly elevated in the cupulolith type of hBPPV.

Case Report

A Case of Tumarkin Otolithic Crisis Treated with Intratympanic Gentamicin Injection: Soo Hyun Joo, Hong-Ju Kim, Hyun-Ji Kim, Kyu-Sung Kim; Res Vestib Sci. 2020;19(1):22-28. Published online March 15, 2020; DOI: https://doi.org/10.21790/rvs.2020.19.1.22

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Abstract PDF: Tumarkin otolithic crisis is an abrupt attack of falling without loss of consciousness because of peripheral vestibular disorders. It occurs without warning in patients with late stage or end-stage of Meniere’s disease. It is an otologic emergency due to the risk of fall down injury, and has been treated with labyrinthectomy, vestibular neurectomy, and intratympanic gentamicin injection. Many reports have reported the efficacy of intratympanic injection of gentamicin (ITIG) as chemical ablation. We report a 58-year-old man with Tumarkin otolothic crisis from Meniere’s disease who presented with sudden drop attack while driving a taxi. He has suffered from recurrent rotatory vertigo accompanied by fluctuating hearing loss and tinnitus in the right ear for years. Despite medical treatment over the next 2 months, he experienced three more sudden drop attacks. He got chemical ablation with ITIG and remains without sudden drop attack until fourteen months later. Tumarkin otolithic crisis is a life-threatening otologic emergency. What we have experienced in this case is that for the safety and quality of life of the patient who suffers from Tumarkin otolithic crisis, aggressive vestibular function ablation with high dose ITIG is necessary.

Review

Vestibular Responses to Gravity Alterations: Nguyen Nguyen, Gyutae Kim, Kyu-Sung Kim; Res Vestib Sci. 2020;19(1):1-5. Published online March 15, 2020; DOI: https://doi.org/10.21790/rvs.2020.19.1.1

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Abstract PDF: Due to the adaptation to environments on Earth, various health-related issues are raised when exposed to different circumstances in space. Of environmental factors in space, gravity alteration has been considered as one of critical environmental changes. The primary inner organ to detect the gravity change is the vestibular system, especially otolith organs, and some limited researches have conducted to understand its mechanical and physiological properties. However, the related consequences were not consistent in despite of well description in systemic effects ranged from the peripheral vestibular system to the central nervous system. Here, we revisited the neuronal and behavioral effects of the gravity alteration on the relevant organs through this review. By representing previous studies for the gravity effects on the peripheral and central vestibular system, this review would provide the concrete understanding of the vestibular responses to the gravity alteration. Also, the physiological responses are expected to provide the useful resources to understand the systemic vestibular responses under the gravity alteration.

Case Reports

Tumarkin Otolithic Crisis Controlled by Endolymphatic Sac Surgery: Seok Min Hong, Il Seok Park, Jae Ho Ban; Res Vestib Sci. 2015;14(1):32-35.

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Abstract PDF: Turmarkin otolithic crisis is a rare feature of Meniere’s disease. It shows sudden falling to the ground with no warning sign. It is an otologic emergency because of the risk of falling, and it has traditionally been treated with labyrinthectomy or vestibular neurectomy. We experienced a 49-year-old male suffering from recurrent drop attack, and found that he had hearing loss, tinnitus or recurrent vertigo on his left ear, and could make a diagnosis him as Tumarkin otolithic crisis. We have performed the endolymphatic sac decompression, considering the hearing preservation and therapeutic opinion of patients. Two years after surgery, he showed intermittent, mild dizzy symptoms, without further drop attack. Therefore, we report our clinical experience with a brief review of literature.

A Case of Tumarkin Otolithic Crisis: Failed to Treat with Intratympanic Gentamicin Injection: Young Hyo Kim, Hoseok Choi, Kyu Sung Kim, Young Mo Kim; Res Vestib Sci. 2010;9(2):76-79.

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Abstract PDF: Tumarkin otolithic crisis is an unusual manifestation of Meniere’s disease that shows sudden falling without loss of consciousness. As a kind of life-threatening otologic emergency due to high risk of injury, the surgical ablation therapy rather than the medical one is preferred. Intratympanic injection of gentamicin (ITIG) is being introduced as a treatment by chemical ablation of vestibular function. The authors report a case of life-threatening Tumarkin otolithic crisis in 76-year-old female, after onset of Meniere’s disease, failed to treat with multiple application of ITIG, and successfully eradicated the symptom with total labyrinthectomy after then. Also we introduce her clinical feature of Tumarkin otolithic crisis. A 76-year-old female visited clinic suffering from recurrent rotatory vertigo accompanied with fluctuating hearing loss and tinnitus on her left ear, and diagnosis of Meniere’s disease was made. Four months after medical treatment, the patient experienced sudden drop attack during walking on the street without any prodromes, and her right wrist and skull base were fractured as a result. She denied to got surgery and ITIG was applied. During 1 year after initial drop attack, she experienced 7 times of severe drop attack and 4 times of ITIG, and finally she accepted to get surgery. The patient no longer suffered from drop attack after total labyrinthectomy later. Tumarkin otolithic crisis is an otologic emergency, may cause life-threatening falling. Our experience from this case is that vestibular ablation by surgical method is needed for safety and quality of life of patients.

Original Articles

Effects of Changes of Plateau and Rise/Fall Times on Ocular Vestibular Evoked Myogenic Potentials: Yeo Jin Lee, Soo Hee Han, Eun Jung Ha, Yong Soo Jung, Hi Boong Kwak, Mun Su Park, Jung Eun Shin, Hong Ju Park; J Korean Bal Soc. 2008;7(2):193-196.

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Abstract PDF: Background and Objectives: The ocular vestibular evoked myogenic potential (OVEMP) is a recently discovered test of labyrinthine function, analogous to the cervical VEMP. Recent works have demonstrated the existence of OVEMPs, which likely reflect otolith-ocular reflex. The purpose of this study was to identify the optimal plateau and rise/fall times of short tone bursts to detect OVEMPs in healthy subjects. Materials and Methods: Thirteen healthy subjects (26 ears) were included in this study. Surface electromyographic activity was recorded from active electrodes placed inferior to each eye. Stimulation with 500 Hz short tone bursts was used. We used a variety of plateau and rise/fall times. Three different plateau times (1, 2, and 3 ms) and rise/fall times (0.5, 1, and 2 ms) were used. The incidence, amplitudes and latencies were compared. Results: VEMP responses were clearly observed in all 26 ears at the plateau time of 2 ms and two rise/fall times (0.5 and 1 ms). The amplitudes in the individual ears tested were lower at the rise/fall time of 2 ms than at the other conditions. The amplitudes were lower at the plateau time of 3 ms compared to the other conditions. When the rise/fall time was prolonged from 0.5 to 2 ms, the n1 and p1 latencies were prolonged in parallel. However, there was no such change in latencies according to the plateau times. Conclusions: Our findings show that the ideal stimulation pattern for evoking OVEMP is at the rise/fall times of 0.5 or 1 ms and the plateau time of 2 ms. The waveform morphology of the VEMP responses observed with this stimulation pattern was simultaneously the most constant and marked. Key words: Evoked potentials, Ocular VEMP, Vestibulo-ocular reflex, Otolith

Results of Otolithic Function Testing and Related Clinical Features in Unilateral Definite Meniere’s Disease: Jae Yun Jung, Jeong Beom Kim, Tae Hyun Moon, Yong Won Chung, Chung Ku Rhee; J Korean Bal Soc. 2007;6(2):207-213.

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Abstract PDF: Background and Objectives: The purpose of this study is to identify the typical pattern of otolithic function tests in unilateral definite Ménière’s disease patients. And we compared with clinical features and other tests results of patients who showed abnormal otolithic function tests. Materials and Method: We reviewed 42 patients (29 patients are female and 13 patients are male) who were diagnosed as unilateral definite Ménière’s disease and underwent otolithic function tests in Hospital from December 2005 to April 2007. Results: The patients who showed abnormal findings in vestibular evoked myogenic potential (VEMP) have suffered for longer period than the others. Those results of VEMP had positive correlation with summating potential/action potential (SP/AP) ratio. The average deviation of subjective visual vertical/ horizontal (SVV/SVH) were relatively higher in that disease patients than normal controls. There was no significant relation between VEMP results and other clinical features and result of other tests (caloric test and pure tone audiometry). Conclusion: The longer prevalence period of Ménière’s disease is, the more susceptability of abnormal VEMP we can expect. In those, SVV/H can go out of normal range. Like a electrocochleography, otolithic function test could play a supportive role in diagnosing of Ménière’s disease.

Otolith Function Tests in Patient with Meniere’s Disease: Hong Ju Park, Jung Eun Shin, Jae Yoon Ahn, Ga Hyun Park, Yong Soo Jung, Hi Boong Kwak, Yeo Jin Lee, Jin Seok Yoo; J Korean Bal Soc. 2007;6(2):127-131.

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Abstract PDF: Background and Objectives: The aims of this study were to measure otolith function using subjective visual vertical (SVV) test and vestibular evoked myogenic potential (VEMP) test in patients with unilateral Meniere’s disease, and to see the relationship of the otolithic impairment with caloric and audiologic results. Materials and Methods: Twenty two patients with unilateral Meniere’s disease who received treatment and also had been tested for pure tone, caloric, SVV and VEMP tests were enrolled. All the tests were done simultaneously. Results: Five of 22 (23%) patients showed abnormal tilt to the lesion side in SVV test, and 13 of 22 (59%) patients showed abnormal VEMP results on the affected side. There was no correlation between SVV tilts and unilateral weakness (UW) in caloric tests or pure-tone average. There was also no difference of UW in patients with or without VEMP abnormalities. Two patients showed abnormal finding in both SVV & VEMP tests. One patient showed UW (47%) and SVV tilt (3.08°) to the lesion side, and the other showed normal UW and SVV tilt (3.22°) to the lesion side. Conclusion: Our results demonstrate that the otolith system was implicated in 16 out of 22 (73%) patients with Meniere’s disease. However, there was no correlation between the abnormal results of the three tests and these findings suggest that impairment of the otolithic function is depending on the extent and/or the localization of Meniere’s disease, suggesting vestibular rehabilitation for the specific lesion might be helpful.

Otolith Function Tests in Patient with Vestibular Neuritis: Hong Ju Park, Jung Eun Shin, Dae Bo Shim, Hyang Ae Shin, Sang Kyun Lim, Jae Yoon Ahn, Yong Soo Jung, Jin Suk Yu; J Korean Bal Soc. 2006;5(1):49-54.

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Abstract PDF: Background
and Objectives: Vestibular evoked myogenic potentials (VEMP) test provides a useful method for assessment of saccule function and the functional integrity of the inferior vestibular nerve, and subjective visual vertical (SVV) abnormalities are presumably related to a lesion of the utricle. The aim(s) of this study were to measure otolith function using SVV and VEMP tests, and to define the influence of the otolithic organs in patients suffering from vestibular neuritis. Materials and Method: From September 2005 to January 2006, twelve patients who received treatment in hospital and also had been tested for caloric test, subjective visual vertical (SVV) and vestibular evoked myogenic potential (VEMP) tests with unilateral vestibular neuritis were enrolled. All the tests were done within 8 days after the onset of their symptoms, simultaneously. The SVV was measured in 34 normal subjects as well as in patients.
Results
Eight of 12 patients showed abnormal tilt to the lesion side in SVV test, and five of 8 patients showed no VEMP on the affected side. There was no correlation between SVV tilts and unilateral weakness (UW) in caloric tests. Two patients with abnormal UW (54, 82%) showed normal finding in SVV & VEMP tests. One patient with abnormal UW (83%) and SVV tilts (18.04˚) to the lesion side was normal in VEMP test. Two patients with abnormal UW (28, 37%) and no response in VEMP test were normal in SVV test.
Conclusion
Our results demonstrate that the incidence of abnormal results were 62.5, 66.7% in VEMP and SVV tests in acute stage of vestibular neuritis, respectively. There was no correlation between the abnormal results of the tests and these findings suggest that impairment of the otolithic function is depending on the extent and/or the localization of vestibular neuritis. Key Words : Vestibular neuritis, Otolith, Vestibular function tests, Subjective visual vertical, Vestibular evoked myogenic potentials

The Effect of Somatosensory Input on Subjective Visual Vertical in Normal Subjects: Dae Bo Shim, Hyun Jong Jang, Hyang Ae Shin, Jae Yoon Ahn, In Bum Lee, Jung Eun Shin, Hong Ju Park; J Korean Bal Soc. 2005;4(2):201-205.

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Abstract PDF: Background
and Objectives: Aims of the study were to determine if the somatosensory input influences on vertical perception by comparing the results with the head or body tilted (15°) to the right and to the left, and to examine the influence of tactile sensation in the perception of verticality in head lateral positions. Materials and Method: We tested 34 normal subjects in their ability to set a straight line to the perceived gravitational vertical. Measurements were taken in static conditions, sitting upright, head tilted (15°), body tilted (15°), and head lateral positions (90°) on the right/left sides with or without physical support under the head.
Results
The normal range of the subjective visual vertical (SVV) was 0.65°±1.23° in upright position. The normal ranges of SVV in head-tilts 15° to the left/right sides were -0.47°±1.76° and 1.88°±2.94°, which were significantly different from those in upright position (E-effect). But the normal ranges of SVV in body-tilts 15° to the left/right were not different from those in upright position. And the normal ranges of SVV in head lateral positions maintained actively and passively were not different each other, but significantly larger than that in upright position (A-effect).
Conclusion
Our results support that neck somatosensory input plays a part in the perception of verticality. In contrast, tactile sensation of the head had no effect on the settings of a visual line to visual vertical in head lateral positions.

Reviews

The Design of Subjective Visual Vertical and Horizontal Measurement Method in Normal Peoples: Gyu Cheol Han, Jong Su Ha, Sun Young Kim, Joo Hyoung Lee, Chang Hyun Cho, Dong Young Kim, Seon Tae Kim; J Korean Bal Soc. 2004;3(2):395-403.

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Abstract PDF: Background
and Objectives : Subjective visual vertical and horizontal presented as test that evaluate otolithic organ. However, was not discussed about condition that is factor influencing in examination or position at examination. Therefore, we wished to evaluate effect of subjective visual vertical and horizontal in each test condition and find repletion item. Materials and Method : Measured subjective visual vertical and horizontal dividing by gender and three age group to 45 normal persons. Do so that there may be axis of rotation of 0.3×20 cm size candlepin on center of screen and lower part of screen to 18 inch LCD monitor at subjective visual vertical. Do so that may be center of screen and left middle at subjective visual horizontal and gave change length and axis of rotation of candlepin. Measured subjective visual vertical and horizontal each 3 times in standing, sitting, supine position in darkroom.
Results
: There are no statistical differences in each positions and distinction of gender and axis of rotation. But there are statistical differences in age groups.
Conclusion
: Difference in age groups means that examination method or control of number of test, preliminary education of patients, assistance need rather than is caused change or abnormality of otolithic organ. Therefore, is thought to be representative test that evaluate function of otolithic organ as clinical test.

Comparison of Vestibule-ocular Reflex of Eccentric Rotation with Centric Rotation in Normal Subjects: Byung Han Cho, Seung Yeun Jang, Ho Suk Choi, Seung Chul Lee, Kyu Sung Kim; J Korean Bal Soc. 2004;3(2):351-335.

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Abstract PDF: Background
and Objectives : Conventional vestibular rotation testing with the head centered on the axis stimulates the semicircular canals evoking compensatory eye movements. By placing subjects off from the axis of rotation, the otolithic organ may also be simultaneously stimulated by additional linear acceleration forces. In the present study, we compared the rotation with subjects placed on axis to those placed in an eccentric position. Materials and Method : In the eccentric rotation, the head of subject was facing outward and placed eccentrically for 33cm on naso-occipital axis. Slow harmonic acceleration test and velocity step test were performed.
Results
: The sinusoidal eccentric rotation at 0.32, 0.64 Hz produced a significantly higher vestibulo-ocular reflex gain than did on axis rotation. In velocity step test, initial slow component velocity was significantly higher in eccentric rotation than in centric rotation.
Conclusion
: These finding suggest that the gain enhancement due to eccentric rotation is a result of tangentiallinear acceleration, probably sensed by the otolithic organ. This study raises the possibility of using eccentric rotation for the diagnosis of the patients with otolithic dysfunction.

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