Research in Vestibular Science

Case Reports

A case of vertebrobasilar dolichoectasia manifesting as sudden sensorineural hearing loss with vertigo: Young Jae Lee, Wonyong Baek, Gi-Sung Nam; Res Vestib Sci. 2024;23(1):32-36. Published online March 15, 2024; DOI: https://doi.org/10.21790/rvs.2024.004

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Abstract PDF: Vertebrobasilar dolichoectasia (VBD) is a rare vascular condition characterized by the elongation, widening, and tortuosity of the vertebrobasilar artery. It can lead to various symptoms due to compression of cranial nerves and brainstem structures. We report a rare case of VBD presenting as sudden sensorineural hearing loss (SSNHL) with vertigo and spontaneous downbeat nystagmus in a 65-year-old woman with a history of hypertension. Magnetic resonance imaging revealed a tortuous and dilated right vertebrobasilar artery compressing the brainstem and left 8th cranial nerve root entry zone, without signs of acute cerebellar stroke. The compression of the anterior inferior cerebellar artery and cervicomedullary junction was also noted, suggesting a vascular cause for her symptoms. Following high-dose steroid treatment, the patient showed significant hearing improvement. This case underscores the importance of considering VBD in patients with unexplained SSNHL and vertigo, highlighting the role of detailed vascular imaging in the diagnosis and management of such cases.

A case of cerebellopontine angle meningioma presenting as neurovascular compression syndrome of the 8th cranial nerve: Jeongin Jang, Sung Kwang Hong, Joonho Song, Hyung-Jong Kim, Hyo-Jeong Lee; Res Vestib Sci. 2024;23(1):28-31. Published online March 15, 2024; DOI: https://doi.org/10.21790/rvs.2023.141

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Abstract PDF: A 54-year-old female patient presented with paroxysmal tinnitus and vertigo for 2 years, which have repeatedly occurred while rotating her neck, and lasted about 10 seconds. An anticonvulsant medication was prescribed with a diagnosis of microvascular compression syndrome on the 8th cranial nerve and audiovestibular evaluation and magnetic resonance imaging (MRI) scan were appointed a week later. In her next visit, she reported the disappearance of paroxysmal audiovestibular symptoms after medication. In the left ear, canal paresis and abnormal auditory brainstem response were observed. In MRI, a large meningioma in the cerebellopontine angle in the vicinity of the internal auditory canal orifice was detected, that was surgically resected by a neurosurgeon. After surgical removal of the tumor, she reported continuous dizziness due to vestibular nerve injury, but the paroxysmal attack of tinnitus and vertigo disappeared without anticonvulsant medication. This case suggests that an imaging study is mandatory when diagnosing microvascular compression syndrome on the 8th cranial nerve.

Complete ocular tilt reaction with subjective visual vertical tilt in a patient with a medial prefrontal cortex lesion: a case report: Hyung Lee, Hyun Ah Kim; Res Vestib Sci. 2024;23(1):24-27. Published online March 15, 2024; DOI: https://doi.org/10.21790/rvs.2023.136

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Abstract PDF: A 61-year-old male patient undergoing chemotherapy for esophageal cancer presented with symptoms of rightward tilting while both sitting and walking. A neurological examination revealed a head tilt, skew deviation with hypertrophy of the left eye, and a rightward shift in his gait. No spontaneous nystagmus was observed, and the vestibulo-ocular reflex was normal. Magnetic resonance imaging of the head revealed a suspected metastatic lesion in the right medial prefrontal cortex. Following the initiation of levetiracetam treatment, the patient demonstrated marked improvement, with the resolution of both head tilt and skew deviation within 1 month. Traditionally, the ocular tilt reaction has been attributed to unilateral or asymmetric dysfunction of the graviceptive pathways extending from the utricle to the upper midbrain lesions. However, this case highlights the potential involvement of the prefrontal cortex in the ocular tilt reaction. Further research is warranted on the role of the prefrontal cortex within the vestibular system.

Original Articles

The clinical significance of arterial stiffness in the differential diagnosis of vertigo: Bang-Hoon Cho, Jae-Myung Kim, Young-In Kim, Seung-Han Lee; Res Vestib Sci. 2024;23(1):16-23. Published online March 15, 2024; DOI: https://doi.org/10.21790/rvs.2024.003

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Abstract PDF Supplementary Material: Objectives
Pulse wave velocity (PWV) is a known indicator of arterial stiffness reflecting vascular damage. However, there are few reports of the relationship between PWV and dizziness/vertigo of a vascular origin. We investigated whether the PWV value could be useful as an ancillary measurement for identifying the etiology of dizziness/vertigo.
Methods
We enrolled dizzy patients from March 2016 to December 2018. The patients with posterior circulation stroke presenting with dizziness/vertigo were categorized as having central vertigo. The patients with vertigo due to benign paroxysmal positional vertigo, Ménière disease, or acute unilateral vestibulopathy were categorized as having peripheral vertigo. The PWV value, ankle-brachial index (ABI), and traditional vascular risk factors were collected.
Results
We consecutively enrolled a total of 93 participants. The PWV values were higher in the central vertigo group (p<0.001), but ABI did not differ between the groups. Among the vascular risk factors, the number of patients with diabetes mellitus, dyslipidemia, and male patients was significantly higher in the central vertigo group. The brachial-ankle PWV (baPWV) values were higher in the central vertigo group, even after adjusting for confounding factors (p<0.01). The receiver operating characteristic curve showed that the sensitivity was 74% and specificity was 81% when the mean baPWV value was 14.78 m/sec.
Conclusions
Increased baPWV values were observed in patients with dizziness/vertigo due to stroke. Measurement of the baPWV value could be an ancillary test for evaluating the cause of dizziness/vertigo, even though more convincing evidence is still required.

Comparison of vestibular evoked myogenic potentials between low and high tone idiopathic sudden sensorineural hearing loss: Sang-Wook Park, Sang Yun Lee, Somi Ryu, Jung Woo Lee, Chae Dong Yim, Dong Gu Hur, Seong-Ki Ahn; Res Vestib Sci. 2024;23(1):11-15. Published online March 15, 2024; DOI: https://doi.org/10.21790/rvs.2024.001

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Abstract PDF: Objectives
Vestibular evoked myogenic potentials (VEMP) have been reported to be useful in evaluating not only vestibular function but also the prognosis of idiopathic sudden sensorineural hearing loss (ISSNHL) patients. Even though low frequency, high frequency, and all frequency-involved ISSNHL groups tend to show varied clinical characteristics, there is a lack of data using VEMP results to analyze these subgroups. We investigated if the VEMP test is a valuable tool to predict recovery from hearing loss in association with different frequencies.
Methods
A total of 26 ISSNHL patients were divided into three different groups impaired with low tone (ascending type), high tone (descending type), and all tones (flat type) based on the initial audiograms. Each group included five, 10, and 11 patents, respectively, and their VEMP results were compared between the three subgroups.
Results
Abnormal VEMP results were found in five of the total 26 ISSNHL patients (19.2%). Two (40.0%), one (10.0%), and two (18.1%) patients of low tone, high tone, and all tone hearing loss groups, respectively, showed abnormal VEMP results. However, there was no statistically significant difference between the three groups.
Conclusions
Even though VEMP is known as a valuable tool for predicting the prognosis of ISSNHL patients, it does not seem to reflect frequency-sensitive aspects of ISSNHL.

Review Article

Virtual reality simulators for temporal bone dissection: overcoming limitations of previous models: Temuulen Batsaikhan, Young Joon Seo; Res Vestib Sci. 2024;23(1):1-10. Published online March 15, 2024; DOI: https://doi.org/10.21790/rvs.2024.002

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Abstract PDF: Temporal bone dissection is a critical skill for otolaryngology trainees: however, it is challenging to master due to the complex anatomy and limited exposure to cadaveric specimens. The aim of this review was to develop and evaluate a novel virtual reality (VR) simulator for temporal bone dissection, addressing the limitations of previous simulators reported in the literature. A comprehensive literature search was conducted in the PubMed, Embase, and Cochrane Library databases from inception to September 2022. The search was limited to studies that evaluated the effectiveness of VR simulators for temporal bone dissection. The quality of the included studies was assessed using the Cochrane Risk of Bias Tool. The results showed that VR simulators can significantly improve temporal bone dissection skills, including anatomical knowledge, instrument handling, and surgical performance. Compared to traditional training methods, VR simulation was associated with faster learning curves, better retention of skills, and greater confidence among trainees. However, some limitations of current VR models were identified, including the lack of haptic feedback, limited realism, and short duration of practice. VR simulators are a valuable adjunct to traditional methods for temporal bone dissection training. The recently developed VR simulator addressed the limitations of previous simulators and demonstrated its potential to enhance the training of clinicians in temporal bone dissection. Future directions for research include further validation of the simulator and exploration of its potential for use in clinical settings.

Corrigendum

Correction: A Case of Patient with Bilateral Cochleovestibular Function Loss due to Infratentorial Superficial Siderosis: Gyuman Lee, Youngmin Mun, Dae Bo Shim; Res Vestib Sci. 2023;22(4):137. Published online December 15, 2023; DOI: https://doi.org/10.21790/rvs.2023.22.4.137; Corrects: Res Vestib Sci 2023;22(3):83

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Case Reports

Arnold-Chiari Malformation Presented with Spontaneous Down-Beating Nystagmus and Gait Disturbance: Minbum Kim, Youn Jin Cho; Res Vestib Sci. 2023;22(4):132-136. Published online December 15, 2023; DOI: https://doi.org/10.21790/rvs.2023.22.4.132

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Abstract PDF Supplementary Material: Arnold Chiari malformation is a disease which is characterized by herniation of a portion of the cerebellum through the foramen magnum. Symptoms vary depending on the extent of the affected area, including posterior neck pain, upper limb pain, paralysis, paresthesia, weakness, dizziness, and ataxia. Among the patients presenting with dizziness, nystagmus is frequently observed, which is primarily characterized by down-beating nystagmus. We experienced a 42- years-old female patient presented with vertigo and gait disturbance, who were diagnosed with type 1 Arnold-Chiari malformation and treated by surgical decompression.

Dural Arteriovenous Fistula Presenting as Acute Unilateral Vestibulopathy: Won Jeong Son, Jieun Roh, Eun Hye Oh, Jae-Hwan Choi; Res Vestib Sci. 2023;22(4):127-131. Published online December 15, 2023; DOI: https://doi.org/10.21790/rvs.2023.22.4.127

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Abstract PDF: Intracranial dural arteriovenous fistula (dAVF) is characterized by an abnormal connection between branches of arteries and veins in the dura mater. Clinical manifestations of dAVF vary depending on their location, feeder arterial supply, amount of shunting, and most importantly, their venous drainage pattern. Acute vertigo has been rarely reported as an initial presentation of dAVF due to venous congestion in the brainstem. We report a patient who presented with acute right vestibulopathy without any brainstem signs in dAVF involving the transversesigmoid sinus. The patient showed abnormal caloric response but normal head impulse in the affected ear. Without any treatment, the patient’s symptoms gradually improved with a normalization of right canal paresis. Follow-up cerebral angiography also revealed a spontaneous regression of the shunt flow and reduction of venous drainage at the right transverse-sigmoid sinus. Based on the results of vestibular function tests and cerebral angiography, acute vertigo in our patient may be ascribed to impaired reabsorption of endolymph by focal venous congestion.

A Case of Ramsay Hunt Syndrome Showing Central Findings due to Brainstem Involvement: Min Hyuk Lee, Min-Beom Kim; Res Vestib Sci. 2023;22(4):120-126. Published online December 15, 2023; DOI: https://doi.org/10.21790/rvs.2023.22.4.120

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Abstract PDF: Ramsay Hunt syndrome occurs when the varicella zoster virus reactivates. Classic findings include the triad of facial paralysis, otic pain and herpetic lesions due to the pathogenesis associated with anterograde axonal reactivation of the varicella zoster virus in the geniculate ganglion. In addition to the classic triad, rare features such as a central type of vestibular function test may be observed due to the retrograde spread of the varicella zoster virus from the geniculate ganglion into the brain stem, including involvement of the vestibular nucleus. We present a case of Ramsay Hunt syndrome in a 57-year-old male patients, manifesting not only the typical triad of symptoms but also the unique features associated with brain stem involvement. This presented as direction-changing gaze-evoked nystagmus and a decrease in gain on both sides on video head impulse test. And brain magnetic resonance imaging showed a lesion in the vestibular nucleus of the brain stem.

Original Articles

Unilateral Vestibulopathy Mimicking Inner Ear Ischemia Modeling Using Photothrombosis and Behavioral Assessment Using EthoVision: Min Seok Song, Min Young Lee, Ji Eun Choi, So-Young Chang, Jae-Hun Lee, John Patrick Cuenca, Nathaniel T. Carpena, Jae Yun Jung; Res Vestib Sci. 2023;22(4):112-119. Published online December 15, 2023; DOI: https://doi.org/10.21790/rvs.2023.22.4.112

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Abstract PDF: Objectives
Inner ear ischemic animal models using photochemical reactions have been devised in various ways. Localized vascular ischemia occurs with 532-nm laser irradiation after systemic rose bengal injection, a known photothrombotic mechanism. The aim of this study is to evaluate a photothrombosis-induced vestibulopathy mimicking behavioral changes in the inner ear ischemia model.
Methods
Seven-week-old male Spraque-Dawley rats were used. Animals were divided into three groups: control group (n=6), sham laser group (n=9), and laser group (n=9). To induce the photothrombosis, animals were injected with rose bengal into the femoral vein and then were irradiated with a 532-nm laser (175 mW for 900 seconds) via transtympanic membrane. To investigate the vestibulopathy after photothrombosis, the behavior tests (tail lift reflex test, air righting reflex test, rotarod test) were performed on the 1st, 3rd, and 7th days after surgery. Additionally, an open field test was conducted and analyzed using EthoVision XT (Noldus).
Results
The laser group exhibited significant behavioral change to mimic vestibulopathy in all assessments. Inducing photothrombosis with rose bengal caused severe gait instability, which precluded rotarod testing. In the tail lift reflex test, the laser group displayed vestibular dysfunction with a lower angle formation compared to the control rats. During the open field test, the laser group exhibited reduced mobility, a condition that persisted in the laser groups for 7 days.
Conclusions
Noninvasive laser irradiation using rose bengal and a 532-nm laser induces photothrombosis in the inner ear of animals, leading to the development of vestibulopathy mimicking imbalanced behavior.

Efficacy of the Fixation Index of Bithermal Caloric Test for Differentiating Brain Lesions in Vestibular Disoder: Young Jae Lee, Wonyong Baek, Sung-Il Cho, Gi-Sung Nam; Res Vestib Sci. 2023;22(4):106-111. Published online December 15, 2023; DOI: https://doi.org/10.21790/rvs.2023.22.4.106

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Abstract PDF: Objectives
This study was performed to investigate the efficacy of the fixation index (FI) of the bithermal caloric test for differentiating brain lesions in vestibular disorder.
Methods
We reviewed the medical records of 286 consecutive dizzy patients who underwent brain magnetic resonance imaging (MRI) and the bithermal caloric test at department of otorhinolarnygology. Central vestibulopathy (CVP) was defined as when corresponding lesion was identified on brain MRI, otherwise peripheral vestibulopathy (PVP) was defined. The FI was defined as the mean slow phase velocity (SPV) with fixation divided by the mean SPV without fixation, and failure was indicated when the FI exceeded 70%.
Results
The CVP confirmed by brain MRI and PVP were 16.8% and 83.2%, respectively. The most common CVPs were cerebellopontine angle tumor (n=19, 39.6%) and chronic cerebellar infarction (n=18, 37.5%). There were 23 cases of CVP (47.9%) and 47 cases of PVP (19.7%) with abnormal number of FI in at least two of the four caloric irrigations. The FI score of right cool (RC), left cool (LC), and right warm (RW) were also increased significantly in patients with CVP (p=0.031 at RCFI, p=0.014 at LCFI, p=0.047 at RWFI, and p=0.057 at LWFI; Mann-Whitney U-test).
Conclusions
If two or more abnormal FIs are detected during bithermal caloric testing, there is a high likelihood of CVP. Consequently, additional brain MRI may be necessary for further evaluation.

Clinical Outcomes of Endolymphatic Sac Decompression Surgery in Menière’s Disease: Hee Won Seo, Young Sang Cho, Won-Ho Chung; Res Vestib Sci. 2023;22(4):97-105. Published online December 15, 2023; DOI: https://doi.org/10.21790/rvs.2023.22.4.97

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Abstract PDF: Objectives
Endolymphatic sac decompression surgery (ESDS) is one of the surgical methods for intractable Menière’s disease (MD), and it is known as a relatively safe treatment that does not cause hearing loss. However, the effectiveness and the degree of vertigo control rate of ESDS are still controversial. In this study, we aimed to evaluate the clinical outcomes of ESDS in intractable MD.
Methods
We retrospectively reviewed 33 patients who underwent ESDS for intractable MD from January 2002 to March 2022. Clinical characteristics of patients, pure tone threshold, medical treatment method, and number of vertigo attacks before and after surgery were assessed. The improvement of hearing and vertigo was evaluated according to the 1995 American Academy of Otolaryngology-Head and Neck Surgery criteria.
Results
Of the 33 patients, the average follow-up period was 21.2 months, with immediate follow-up within 2 months (28 patients), short term between 2 and 6 months (27 patients), and long term at 12 months or later (29 patients). In the immediate hearing threshold, both air conduction and bone conduction showed slight deterioration, but there was no significant change in the long-term hearing threshold. At long-term follow-up, 12 patients (41.4%) were able to live without medication, and 18 patients (62.1%) showed improvement in their vertigo symptoms. In addition, patients who showed improvement in hearing also showed improvement in vertigo at the same time.
Conclusions
ESDS in intractable MD is a relatively safe and effective treatment method for reducing vertigo attack without worsening hearing threshold.

Video Report

A Case of Congenital Nystagmus Showing Reversed Optokinetic Nystagmus: Han Cheol Lee, Seungjoon Yang, Sung Huhn Kim, Seong Hoon Bae; Res Vestib Sci. 2023;22(3):95-96. Published online September 15, 2023; DOI: https://doi.org/10.21790/rvs.2023.22.3.95

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PDF Supplementary Material

Case Report

A Rare Case of Isolated Infarcts of the Pons with Sudden Vertigo: Clinical Features and Imaging Findings: Dong Hwan Kwon, Eun kyung Jeon, Young Joon Seo; Res Vestib Sci. 2023;22(3):89-94. Published online September 15, 2023; DOI: https://doi.org/10.21790/rvs.2023.22.3.89

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Abstract PDF: Isolated infarcts of the pons (IIP) are a rare subtype of ischemic stroke, accounting for less than 1% of all strokes. It refers to a specific type of ischemic stroke that occurs within the pons region of the brain. IIP can be associated with vertebrobasilar insufficiency in certain cases. This case report describes a 64-year-old female patient who presented with acute vertigo and spontaneous nystagmus to the lesion side, ultimately diagnosed with IIP in the posterior right side of pons. Tegmental pontine infarcts typically manifest as oblique small (lacunar) infarctions that are localized in the mediolateral tegmental area of the middle to upper pons. The patient’s symptoms resolved spontaneously, but a 2-mm infarct was confirmed by brain diffusion magnetic resonance imaging. This case highlights the distinctive symptoms associated with IIP and emphasizes the importance of careful neurological examination and advanced neuroimaging techniques for accurate diagnosis.

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