Research in Vestibular Science

Letter to the editor

Isolated ocular tilt reaction in unilateral thalamic infarction: a short case report: Seongjin Jeon, Jae-Chan Ryu, Ji-Yun Park; Res Vestib Sci. 2024;23(4):165-167. Published online December 15, 2024; DOI: https://doi.org/10.21790/rvs.2024.025

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Original Articles

Associations between Dizziness Handicap Inventory scores and vestibular function tests: a cross-sectional survey: Eun-Ju Jeon, Chae-Hyun Lim, Eun-Jin Son, Chang-Yeong Jeong, Ji Hyung Lim, Hyun Jin Lee; Res Vestib Sci. 2024;23(4):156-164. Published online December 15, 2024; DOI: https://doi.org/10.21790/rvs.2024.023

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Abstract PDF: Objectives
This study aims to evaluate the relationship between subjective dizziness disability, as assessed by the Dizziness Handicap Inventory (DHI), and objective vestibular function test (VFT) results in patients presenting with dizziness.
Methods
We conducted a retrospective review of 177 patients who completed the DHI, vertigo visual analog scale, and disability scale at their initial visit. Objective VFTs included videonystagmography with caloric testing, cervical vestibular evoked myogenic potential (cVEMP), and the sensory organization test (SOT). Statistical analyses were conducted to assess correlations and differences in DHI scores based on VFT results and clinical characteristics.
Results
The DHI scores indicated a higher perceived dizziness handicap among female patients compared to males (p=0.012). Chronic dizziness was associated with elevated DHI scores in specific items (DHI-2, DHI-12, and DHI-21; p<0.05). Patients with abnormal caloric responses exhibited higher scores in several DHI items and subscales (DHI-4, DHI-12, DHI-14, DHI-17, DHI-19, DHI-23, physical, emotional, and functional; p<0.05). No significant differences were found in cVEMP results. Only one SOT condition (equilibrium score 5) showed a statistically significant but weak association with DHI scores (r=–0.151, p=0.045).
Conclusions
There were limited correlations between objective vestibular test outcomes and subjective dizziness disability. These findings underscore the multidimensional nature of dizziness and the importance of integrating subjective and objective measures for a comprehensive clinical assessment.

Various symptoms and signs of vestibular paroxysmia in a tertiary neurotologic clinic: a retrospective comparative study: Tae Uk Cheon, Eun Hye Cha, Yehree Kim, Hong Ju Park; Res Vestib Sci. 2024;23(4):147-155. Published online December 15, 2024; DOI: https://doi.org/10.21790/rvs.2024.021

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Abstract PDF Supplementary Material: Objectives
Vestibular paroxysmia (VP) is characterized by brief episodes of vertigo due to neurovascular cross-compression (NVCC) of the eighth cranial nerve. This study aimed to analyze the clinical features of VP patients in a tertiary neurotologic clinic using the 2008 and 2016 diagnostic criteria and to compare these features.
Methods
A retrospective review was conducted on patients diagnosed with definite or probable VP at the Asan Medical Center from May 2012 to May 2013. Patients underwent comprehensive evaluations including history taking, physical examination, audiometry, vestibular function tests, and magnetic resonance imaging (MRI). The 2008 and 2016 diagnostic criteria for VP were applied, and clinical characteristics were compared.
Results
Nineteen patients were included (14 females and five males; mean age, 57.9±14.5 years). According to the 2008 criteria, 17 patients were diagnosed with definite VP and two with probable VP; however, using the 2016 criteria, nine were definite and two were probable VP. NVCC was observed in 88.9% of patients under the 2016 criteria. MRI revealed NVCC predominantly involving the anterior inferior cerebellar artery. Patients with cerebellopontine angle (CPA) tumors presenting with VP-like symptoms responded to medication.
Conclusions
The 2016 diagnostic criteria for VP allow for a syndromic diagnosis based solely on clinical features. Neurovascular contact is commonly observed in VP patients, and CPA tumor can present VP-like symptoms and respond to carbamazepine. Although MRI is not included in the current criteria, it can be beneficial in diagnosis by identifying neurovascular contact and distinguishing CPA tumors.

Review Articles

Exploring the nexus: unilateral vestibulopathy and visuospatial cognitive impairments: Sun-Young Oh, Thanh Tin Nguyen, Marianne Dieterich; Res Vestib Sci. 2024;23(4):132-146. Published online December 15, 2024; DOI: https://doi.org/10.21790/rvs.2024.014

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Abstract PDF: The interplay between vestibular disorders and visuospatial impairments has long captured scholarly attention. While evidence robustly supports visuospatial deficits in bilateral vestibulopathy, findings regarding unilateral vestibulopathy remain equivocal. Recent studies, both animal-based employing vestibular deafferentation models and human-based involving spatial cognitive tasks, hint at potential visuospatial cognitive impairments in individuals with acute and chronic unilateral vestibulopathy. Nevertheless, these results are preliminary and necessitate further rigorous investigation. The posture-first principle is evident in cognitive-motor dual tasks among patients with vestibular disorders. This review synthesizes these emergent insights, aiming to lay a groundwork for future studies that seek to elucidate this complex relationship further.

Clinical application of virtual reality for vestibular rehabilitation: Sung Kwang Hong; Res Vestib Sci. 2024;23(4):124-131. Published online December 15, 2024; DOI: https://doi.org/10.21790/rvs.2024.019

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Abstract PDF: Virtual reality has emerged as a promising tool in vestibular rehabilitation therapy (VRT), offering immersive and interactive environments that enhance patient engagement and adherence to therapy. Its potential lies in delivering controlled, customizable exercise protocols that simulate real-world challenges in a safe, monitored environment. This allows healthcare providers to tailor exercises based on gaze stabilization, vestibulo-ocular reflex training, and balance training, according to a patient’s specific complaints, symptoms, and progress. While cybersickness is a potential concern with virtual reality interventions, patients with vestibular loss are generally less susceptible to the visual-vestibular mismatch that often causes motion sickness. Studies have shown that side effects, such as nausea or discomfort from cybersickness, are minimal for most patients undergoing virtual reality-based VRT. Despite these promising results, further research is needed to fully validate the effectiveness of virtual reality interventions in VRT. This article will explore the current status and future potential of virtual reality in VRT, including considerations for its clinical application and areas for future research.

Digital therapeutics and telemedicine for benign paroxysmal positional vertigo and other vestibular disorders: a review: Eun-Hyeok Choi, Hyo-Jung Kim, Ji-Soo Kim; Res Vestib Sci. 2024;23(4):115-123. Published online December 15, 2024; DOI: https://doi.org/10.21790/rvs.2024.018

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Abstract PDF: In the recent wave of digital transformation, digital therapeutics and telemedicine are changing the concepts in the management of benign paroxysmal positional vertigo and other vestibular disorders. These technologies provide accessible and cost-effective solutions amid the ongoing digital revolution in healthcare. This review article covers the recently advanced digital therapeutics for vestibular disorders that include questionnaire- or artificial intelligence-based diagnostic algorithms, telemedicine and self-application of canalith repositioning therapy, wearable devices for monitoring of eye movements during the attacks of dizziness/vertigo, and metaverse for vestibular rehabilitation. Integration of these digital technologies would improve diagnostic accuracy and treatment efficacy, reduce the economic burden associated with vestibular disorders, and promise a revolutionary shift in patient care towards personalized medicine.

Case Reports

Horizontal nystagmus with velocity-increasing waveforms in delayed post-hypoxic leukoencephalopathy: a case report: Eugene Jung, Suk-Min Lee, Seo-Young Choi, Kwang-Dong Choi; Res Vestib Sci. 2024;23(3):111-113. Published online September 15, 2024; DOI: https://doi.org/10.21790/rvs.2024.016

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Abstract PDF Supplementary Material: Abnormal eye movements in unconscious patients serve as crucial diagnostic instruments, offering insights into the function of the central nervous system. Understanding these movements can aid in diagnosing the cause of unconsciousness, localizing brain lesions, and predicting outcomes. We report a patient who presented with spontaneous horizontal nystagmus unaffected by light in delayed post-hypoxic encephalopathy. Video-oculography showed exponentially increasing slow phases, with an amplitude ranging from 3° to 9° and a frequency of 0.5 Hz. Based on the results of oculography and neuroimaging, persistent horizontal nystagmus in our patient may be ascribed to an unstable neural integrator, possibly caused by disrupted cerebellar feedback mechanisms for horizontal gaze holding.

Fluctuating high-frequency hearing loss with vertigo: is it Menière’s disease? A case report: Minho Jang, Dong-Han Lee, Jiyeon Lee, Chang-Hee Kim; Res Vestib Sci. 2024;23(3):106-110. Published online September 15, 2024; DOI: https://doi.org/10.21790/rvs.2024.011

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Abstract PDF Supplementary Material: This study describes an unusual case of fluctuating unilateral high-frequency hearing loss with vertigo resembling Menière’s disease. The current diagnostic criteria for definite Menière’s disease include audiometrically documented low- to medium-frequency sensorineural hearing loss on at least one occasion before, during, or after an episode of vertigo. This case presented a diagnostic dilemma. Brain MRI was nonspecific, and a bithermal caloric test showed unilateral weakness of 44% on the affected side. The results of electrocochleography and cervical vestibular evoked myogenic potential tests were within the normal ranges. Persistent geotropic or ageotropic positional nystagmus was observed during each vertigo attack; the mechanism underlying this characteristic nystagmus needs further investigation.

Original Articles

Saccadic oscillations as a possible indicator of dizziness due to choline esterase inhibitors: an observational study with video-oculography: Ileok Jung, Moon-Ho Park, Ji-Soo Kim; Res Vestib Sci. 2024;23(3):101-105. Published online September 15, 2024; DOI: https://doi.org/10.21790/rvs.2024.015

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Abstract PDF Supplementary Material: Introduction: Cholinesterase inhibitors (ChEIs) are widely used to treat mild to moderate Alzheimer disease and vascular dementia. Even though dizziness due to medication of ChEIs has been ascribed to adverse effects on the cardiovascular or central nervous system, the mechanisms remain unclear and objective indicators are not available.
Methods
We recorded the eye movements using video-oculography in three patients who developed dizziness and unsteadiness after initiation or increment of ChEI, donepezil (Aricept).
Results
The patients showed frequent saccadic oscillations that improved after discontinuation of ChEI.
Conclusions
Frequent saccadic oscillations may be an indicator of dizziness in patients taking ChEIs.

Comparison of the outcomes of treatment with an oral diuretics with steroid and steroid only for acute low-tone hearing loss: a prospective randomized controlled trial: Seok Min Hong, Yeso Choi, Sung Min Park, Jae Yong Byun; Res Vestib Sci. 2024;23(3):95-100. Published online September 15, 2024; DOI: https://doi.org/10.21790/rvs.2024.012

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Abstract PDF: Objectives
This study aimed to compare the efficacy of a combined steroid and diuretic (isosorbide) treatment with that of steroid-only treatment in patients with acute low-tone sensorineural hearing loss (ALHL).
Methods
A total of 34 patients with ALHL were recruited between January 2018 and December 2019 and randomized into two groups: a steroid-with-diuretic (isosorbide) group and a steroid-only group. The steroid-with-diuretic group received oral methylprednisolone for 10 days and isosorbide for 14 days, while the steroid-only group received methylprednisolone for 10 days. Hearing outcomes were measured using pure-tone audiometry at 8 weeks posttreatment. The outcomes were the absolute hearing gain at low frequencies (125, 250, and 500 Hz) and the recovery rate, which was classified into complete, partial, unchanged, progressive, and fluctuating.
Results
Of 34 patients, 30 (15 in each group) were analyzed. No significant differences were observed in baseline characteristics between the groups. The steroid-with-diuretic group showed higher absolute hearing gains at all three low frequencies than the steroid-only group, but the differences were not statistically significant complete recovery was observed in 13 patients in each group, with partial recovery in two patients in the steroid-with-diuretic group and unchanged outcomes in two patients in the steroid-only group. No patient exhibited disease progression.
Conclusions
Although combined steroid and diuretic therapy yielded better hearing outcomes than steroid-only therapy, the differences were not statistically significant. Further studies with larger sample sizes and extended follow-up periods are necessary to confirm these findings.

Does dimenhydrinate delay recovery of vestibular ocular reflex in acute unilateral vestibulopathy? A retrospective comparative study: Minah Shin, Chae-Young Kim, Ji Eun Choi, Jae Yun Jung, Min Young Lee; Res Vestib Sci. 2024;23(3):89-94. Published online September 15, 2024; DOI: https://doi.org/10.21790/rvs.2024.006

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Abstract PDF: Objectives
Acute unilateral vestibulopathy (UVP), also known as vestibular neuritis, is the third most common peripheral vestibulopathy. The acute autonomic symptoms of UVP can be controlled by the H1-receptor antagonist dimenhydrinate. Despite concerns about prolonged recovery from suppressed vestibular compensation when using dimenhydrinate, research is limited. Thus, we investigated the effect of dimenhydrinate on the recovery of UVP patients.
Methods
We retrospectively analyzed patients who were diagnosed with UVP from April 2018 to April 2022. The patients were divided into those who were prescribed dimenhydrinate during admission and those who were not. Recovery from UVP was defined subjectively and objectively. Subjective recovery (SR) had occurred in a patient whose dizziness clearly subsided. Objective recovery (OR) was used when the video head-impulse test (VHIT) or rotary chair test (RCT) no longer indicated vestibular dysfunction.
Results
Dimenhydrinate was prescribed to 15 patients (19.0%) during admission. The dimenhydrinate group had smaller proportions of SR and OR at 3 months after diagnosis of UVP. In terms of VHIT, the non-dimenhydrinate group had a greater increase in gain for the 3 months than the dimenhydrinate group in the semicircular canals when measured by the VHIT. The difference in gain between the two groups was significant at 0.16 Hz during follow-up RCT.
Conclusion
These results suggest that dimenhydrinate should be carefully used in UVP patients as it may have a negative effect on vestibular compensation.

Review Articles

Treatment of hemodynamic orthostatic dizziness/vertigo: Hyun Ah Kim; Res Vestib Sci. 2024;23(3):79-88. Published online September 15, 2024; DOI: https://doi.org/10.21790/rvs.2024.017

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Abstract PDF: Orthostatic dizziness occurs when a person feels dizzy or lightheaded upon standing up. Hemodynamic orthostatic dizziness can result from autonomic dysfunction, such as orthostatic hypotension or postural tachycardia syndrome. The International Classification of Vestibular Disorders has established diagnostic criteria for hemodynamic orthostatic dizziness/vertigo. These criteria help clinicians understand the terminology associated with orthostatic dizziness/vertigo and differentiate it from dizziness caused by global brain hypoperfusion and other etiologies. Effective treatment involves interpreting the results of autonomic function tests, which can lead to improvements in orthostatic dizziness and help prevent falls related to this condition. This paper discusses general management strategies and specific treatments for orthostatic hypotension and postural tachycardia syndrome, highlighting the importance of tailored care based on the most recent clinical insights.

Review on the impact of spaceflight stressors on the vestibular system: beyond microgravity to space radiation: Hui Ho Vanessa Chang, Kyu-Sung Kim; Res Vestib Sci. 2024;23(3):71-78. Published online September 15, 2024; DOI: https://doi.org/10.21790/rvs.2024.013

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Abstract PDF: Understanding the effects of microgravity on the vestibular system has been a primary focus of space research, driven by the need to counteract the often-debilitating impacts of altered gravity environments and maintain operational performance in space. Research using both space-based and ground-based models has identified structural and functional changes in the vestibular system, highlighting its significant capacity for sensorimotor adaptation. As human space exploration progresses towards missions beyond low Earth orbit for extended periods, additional stressors, such as space radiation, may impact the vestibular system. Early studies on space radiation using animal models and insights from radiotherapy have shown that the vestibular system is more vulnerable to radiation than previously understood. This paper provides a brief review of (1) dysfunctions in spatial orientation, gaze stabilization, posture, and locomotion observed in astronauts; (2) ground-based experiments on animals that likely explain these vestibular and sensorimotor dysfunctions; and (3) studies examining the effects of radiation on the vestibular system and its implications for vestibular function in space.

Smartphones versus goggles for video-oculography: current status and future direction: Pouya Barahim Bastani, Shervin Badihian, Vidith Phillips, Hector Rieiro, Jorge Otero-Millan, Nathan Farrell, Max Parker, David Newman-Toker, Ali Saber Tehrani; Res Vestib Sci. 2024;23(3):63-70. Published online September 15, 2024; DOI: https://doi.org/10.21790/rvs.2024.009

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Abstract PDF: Assessment of eye movements is the cornerstone of diagnosing vestibular disorders and differentiating central from peripheral causes of dizziness. Nonetheless, accurate assessment of eye movements is challenging, especially in the emergency department and primary care settings. To overcome this challenge, clinicians objectively measure eye movements using devices like video-oculography (VOG) goggles, which provide a video recording of the eye and quantified eye position traces. However, despite the value of VOG goggles in studying eye movements, barriers such as high prices and the need for dedicated operators have limited their use to subspecialty clinics. Recent advancements in the hardware and software of smartphones have positioned them as potential alternatives to VOG goggles that can reliably record and quantify eye movements. Although currently not as accurate as VOG goggles, smartphones can provide a cheap, widely available tool that can be used in various medical settings and even at home by patients. We review the current state and future directions of the devices that can be used for recording and quantifying eye movements.

Video Report

Aperiodic alternating nystagmus in acute lateral medullary infarction: a video report: Ji-Yun Park; Res Vestib Sci. 2024;23(2):61-62. Published online June 14, 2024; DOI: https://doi.org/10.21790/rvs.2024.010

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