Research in Vestibular Science

Original Article

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

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 Report

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 Article

Serum otolin-1 level is specific to benign paroxysmal positional vertigo: Hoon Kim, Eun Ji Kim, Eunjin Kwon, Seong-Hae Jeong; Res Vestib Sci. 2024;23(2):46-52. Published online June 14, 2024; DOI: https://doi.org/10.21790/rvs.2024.008

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Abstract PDF: Objectives
When we see patients with a history of positional vertigo (PV), many patients are diagnosed with benign paroxysmal PV (BPPV) by performing a typical history and nystagmus during a positioning maneuver. Recent studies reported that Otolin-1 can be detected in serum and that its levels significantly increase with age and BPPV. Herein, we tried to study the relationship between serum otolin-1 level and the other clinical aspects in patients with PV.
Methods
We measured the serum levels of otolin-1 in 117 BPPV patients (82 females; age range, 43–92 years; mean age±standard deviation [SD], 68.5±10.5 years), referred to as the BPPV group; and nine patients (seven females; age range, 61–79 years; mean age±SD, 66.9±5.9 years) with PV not compatible with BPPV, referred to as another PV group. All the BPPV patients were treated with an appropriate canal repositioning maneuver followed by blood sampling within 1 week.
Results
The serum levels of otolin-1 were higher in the BPPV group than in another PV group (mean±SD, 350.1±319.1 pg/mL vs. 183.6±134.1 pg/mL, respectively; p=0.037). However, there were no differences in both laboratory findings (serum vitamin D, C-telopeptide of type collagen, and bone mineral density) and clinical findings (age, sex, vertigo duration, ear disease, ear symptom, migraine, motion sickness, trauma, and previous BPPV) between these two groups.
Conclusions
Serum otolin-1 level could help predict the current existence of BPPV in patients with PV. However, further validation studies are needed.

Case Report

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.

Original Article

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.

Case Report

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.

Original Article

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.

Case Reports

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 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.

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(3):83-88. Published online September 15, 2023; DOI: https://doi.org/10.21790/rvs.2023.22.3.83; Correction in: Res Vestib Sci 2023;22(4):137

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Abstract PDF: Superficial siderosis (SS) is a rare neurodegenerative condition characterized by hemosiderin deposition in the central nervous system, which sometimes leads to sensorineural hearing loss and vestibular dysfunction. This case report details the diagnosis and treatment of a 63-year-old female patient presenting with a yearlong history of postural instability and recent symptoms of sudden right-sided hearing loss and imbalance. Physical examination and imaging revealed bilateral deafness and infratentorial SS. Treatment, including medication, vestibular exercises, high-dose steroids, and hyperbaric oxygen therapy, led to a significant alleviation of dizziness but no improvement in hearing. This case emphasizes the need for clinicians to consider SS in patients presenting with sudden-onset hearing loss and dizziness, even without prior any medical history or trauma, to accurately identify the underlying cause.

A Case of Delayed Audiovestibulopathy after Posterior Circulation Ischemic Stroke: Hyun Su Lee, Eun Kyung Jeon, Dong Hwan Kwon, Tae Hoon Kong; Res Vestib Sci. 2023;22(3):77-82. Published online September 15, 2023; DOI: https://doi.org/10.21790/rvs.2023.22.3.77

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Abstract PDF: Distinguishing central and peripheral causes of dizziness is vital. A case is presented where a 42-year-old man with a history of posterior circulation ischemic stroke developed acute unilateral vestibulopathy with hearing loss. Clinical examination revealed signs of vestibular dysfunction on the left side. Audiometry confirmed deafness on the left, but imaging ruled out new central issues. The patient was diagnosed with audiovestibulopathy and treated with steroids, antiviral agents, intratympanic injections, and hyperbaric oxygen therapy. Hearing loss persisted, but dizziness improved with vestibular rehabilitation. Poststroke patients should be closely monitored for peripheral complications. Further research should explore the benefits of antiplatelet therapy in vascular-related conditions, even without clear central lesions.

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

Re-fixation Saccade at Video-Head Impulse Test in Patients with Sudden Sensorineural Hearing Loss: Dong Hyuk Jang, Sun Seong Kang, Hyun Joon Shim, Yong-Hwi An; Res Vestib Sci. 2023;22(2):46-51. Published online June 15, 2023; DOI: https://doi.org/10.21790/rvs.2023.22.2.46

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Abstract PDF: Objectives
This study was performed to evaluate characteristics and their prognostic value of video-head impulse test (vHIT) in sudden sensorineural hearing loss (SSNHL) with vertigo.
Methods
Of the 612 patients with a diagnosis of SSNHL from 2010 to 2018, 110 patients (18.0%) with vertigo and 39 patients (6.4%) with vHIT results were recruited. The patients were evaluated for their pure-tone hearing average (at initial, 1-month, and 6-month visit), the presence of re-fixation saccade and gains at vHIT, the canal paresis (CP) at ccaloric test.
Results
Patients with saccade (+) showed higher pure-tone averages than those with saccade (‒) on initial and follow-up audiograms. The improvement in pure-tone averages was less in the saccade (+) group than in the saccade (‒) group. There was no significant difference of hearing recovery between SSNHL patients with normal gain and those with decreased gain. There was no difference of hearing improvement between CP (+) and CP (‒) groups according to the presence of re-fixation saccade.
Conclusions
Concurrent re-fixation saccade at vHIT is a negative prognostic factor of hearing function in SSNHL. Re-fixation saccade in SSNHL may suggest widespread damages to both the cochlea and the vestibule, leading to the poor prognosis.

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