BackgroundThe number of intratympanic gentamicin (ITG) injections needed to achieve vertigo control in patients with intractable Meniere's disease (MD) may vary from a single dose to several instillations. Changes in different vestibular test results have been used to define an endpoint of treatment, including the decrease of the vestibulo-ocular reflex (VOR) gain elicited by the head-impulse test. ObjectiveTo assess the accuracy of the VOR gain reduction after horizontal canal stimulation, as measured with the video head-impulse test (vHIT) 1 month after the first intratympanic injection, in predicting the need for one or more instillations to control vertigo spells in the long term. MethodsThe VOR gain reduction was calculated in 47 patients submitted to (ITG) therapy 1 month after the first instillation. ResultsSingle intratympanic treatment with gentamicin has a 59.6% efficacy in vertigo control in the long term. Hearing change in the immediate period after treatment (1 month) is not significant to pre-treatment result and is similar for patients who needed multiple doses due to recurrence. Chronic disequilibrium and the need for vestibular rehabilitation were less frequent in patients with a good control of vertigo with just one single injection of gentamicin. A fair accuracy was obtained for the VOR gain reduction of the horizontal canal (area under the curve = 0.729 in the Receiver Operating Characteristic analysis) in predicting the need for one or more ITG. ConclusionsSingle intratympanic treatment with gentamicin is an effective treatment for patients with MD. That modality of treatment has very limited damaging effect in hearing. The degree of vestibular deficit induced by the treatment is significant as measured by the reduction in the gain of the VOR but not useful for prognostic purposes.

Background: Although diagnostic criteria have been established for superior canal dehiscence syndrome, cases in which the diagnosis is not easy are frequent. On those occasions, some tests such as vibration-induced nystagmus or vestibular-evoked myogenic potentials can offer invaluable help due to their high sensitivity and specificity. Methods: We studied 30 patients showing superior canal dehiscence or "near-dehiscence" in a CT scan. Skull vibration-induced nystagmus and high frequency ocular vestibular-evoked myogenic potentials are performed in each patient. The aim of the study is to determine how useful both tests are for detection of superior canal dehiscence or near-dehiscence. Results: Of the 60 temporal bones studied, no dehiscence was the result in 22, near-dehiscence in 17 and a definite finding in 21. In 10/30 patients, there was no SVIN (Skull vibration induced nystagmus) during otoneurological testing, while in 6/30, induced nystagmus was mainly horizontal, and in 14/30 there was vertical up-beating. All patients had a positive oVEMP (Ocular vestibular evoked myiogenic potentials) at 0.5 kHz in both ears and the HFoVEMP (High frequency ocular vestibular evoked myiogenic potentials) response was positive in 25/60 (41.6%) of the ears studied and in 19/30 of the patients evaluated (in 6 it was positive in both ears). Up-beat SVIN will point to a SCD (Superior Canal Dehiscence) mainly when HFoVEMP are present, and when this is negative there is a high probability that it is not a SCD. Conclusions: When SVIN and HFoVEMP results are added (or combined), they not only improve the possibilities of detecting SCD, but also the affected side.

Background: Hearing loss causes a significant reduction in the quality of life of patients with Ménière's disease. Although speech recognition is also affected, it has not been extensively studied. The objective of the study was to describe speech recognition behavior during a prolonged period in patients with unilateral Ménière's disease. Methods: A prospective case-control study was performed. The case group included patients with defined unilateral Ménière's disease and the control group included patients with progressive non-fluctuating hearing loss. Patients underwent an auditory evaluation periodically. Pure-tone audiometry and speech recognition tests-speech recognition threshold and speech discrimination score-were administered. The dissociation between pure-tone audiometry and speech recognition was assessed through a linear regression analysis. During follow-up, Ménière's disease patients were subdivided into a stable and fluctuating subgroup (a change of >20% in the speech discrimination score with a change no greater than 15 dB in pure-tone audiometry). Results: The average follow-up time was 79.9 months. Fifty-seven patients were included (30 cases, 27 controls). Dissociation between puretone audiometry and speech recognition threshold began to appear in the case group after 21 months, and it was statistically significant at 108 months. Duration of the disease was the only variable studied that influenced the dissociation. The fluctuation subgroup in cluded 56.6% of the cases. Conclusion: We described 2 audiological peculiarities in Ménière's disease patients: dissociation between pure-tone audiometry and speech recognition during the evolution of the disease and the fluctuation of speech recognition regardless of the change in pure-tone audiometry. Our results highlight the importance of performing speech recognition tests during follow-up in patients with Ménière's disease.

OBJECTIVE: Main objectives for this study were to develop a quantification method to obtain a Perez-Rey (PR) score adapted to the VVOR test and to evaluate the correlation of the PR score obtained with quantified VVOR with the PR score of the vHIT test. METHODS: A new PR score calculation method for quantified VVOR test was developed using the MATLAB computational software based on saccadic response time latency variability between each head oscillation cycle of the VVOR test. Retrospective correlation between PR scores in VVOR and vHIT tests, performed in the same vHIT testing session for patients with vestibular neuritis and vestibular neurectomy, was performed to correlate new PR (VVOR) score with the classic PR (vHIT) score. RESULTS: Thirty patients were included: 11 post-neurectomy and 19 subacute vestibular neuritis. Pearson's correlation coefficient (R-2) for the overall sample was 0.92 (p < 0.001) and 95% confidence interval was 0.85 - 0.96. In the linear mixed-effects statistical model developed, only PRVHIT and PRVVOR scores showed statistical association in Wald X-2 test (p = 0.008). CONCLUSION: The new developed PR score for synchronization measurement of saccadic responses in VVOR testing is a valid method that outputs synchronization values and highly correlates with PR score in vHIT test.

Background: Meniere's disease is often characterized by a changing horizontal nystagmus during the crisis; however, vertical nystagmus is not often detected. The horizontal nystagmus is frequently studied in the irritative or destructive phases of the disease. Clinical findings: We report the case of a 70 years-old man suffering for 3 years of Meniere's disease in his right ear. During an attack we found an infrequent nystagmus that was a downbeat nystagmus in primary position. He was then closely followed in the ward during 5 days and daily tests were performed. We first ruled out a central cause and were able to explain that as due to a peripheral deficit in the right posterior semicircular canal. Other features of the vertigo attacks in patients with MD were recorded. We studied a patient presenting a vertigo attack with a downbeat nystagmus. Our findings show that this nystagmus was caused by his own Meniere's disease, specifically by a posterior canal hypofunction, and not by a central disorder. There is no evidence about this kind of nystagmus in Meniere disease and, to the best to our knowledge, this is one of the first reports its evaluation using the test nowadays available. Conclusion: In this case, our result demonstrate that the downbeat nystagmus was caused by a hypofunction of the posterior semicircular canal.

Objective: Several studies have demonstrated the possibility to obtain vestibular potentials elicited with electrical stimulation from cochlear and vestibular implants. The objective of this study is to analyze the vestibular-evoked myogenic potentials (VEMPs) obtained from patients implanted with cochlear and vestibulo-cochlear implant. Material and Methods: We compared two groups: in the first group, four cochlear implant (CI) recipients with present acoustic cVEMPs before CI surgery were included. In the second group, three patients with bilaterally absent cVEMPs and bilateral vestibular dysfunction were selected. The latter group received a unilateral cochleo-vestibular implant. We analyze the electrically elicited cVEMPs in all patients after stimulation with cochlear and vestibular electrode array stimulation. Results: We present the results obtained post-operatively in both groups. All patients (100%) with direct electrical vestibular stimulation via the vestibular electrode array had present cVEMPs. The P1 and N1 latencies were 11.33-13.6 ms and 18.3-21 ms, respectively. In CI patients, electrical cVEMPs were present only in one of the four subjects (25%) with cochlear implant ("cross") stimulation, and P1 and N1 latencies were 9.67 and 16.33, respectively. In these patients, the responses present shorter latencies than those observed acoustically. Conclusions: Electrically evoked cVEMPs can be present after cochlear and vestibular stimulation and suggest stimulation of vestibular elements, although clinical effect must be further studied.

Background: Endolymphatic hydrops (EH) is the histopathological hallmark of Ménière's disease (MD) and has been found by in vivo magnetic resonance imaging (MRI) in patients with several inner ear syndromes without definite MD criteria. The incidence and relevance of this finding is under debate. Purpose: The purpose of the study is to evaluate the prevalence and characteristics of EH and audiovestibular test results in groups of patients with fluctuating audiovestibular symptoms not fulfilling the actual criteria for definite MD and compare them with a similar group of patients with definite MD and a group of patients with recent idiopathic sudden neurosensory hearing loss (ISSNHL). Material and Methods: 170 patients were included, 83 with definite MD, 38 with fluctuating sensorineural hearing loss, 34 with recurrent vertigo, and 15 with ISSNHL. The clinical variables, audiovestibular tests, and EH were evaluated and compared. Logistic proportional hazard models were used to obtain the odds ratio for hydrops development, including a multivariable adjusted model for potential confounders. Results: No statistical differences between groups were found regarding disease duration, episodes, Tumarkin spells, migraine, vascular risk factors, or vestibular tests; only hearing loss showed differences. Regarding EH, we found significant differences between groups, with odds ratio (OR) for EH presence in definite MD group vs. all other patients of 11.43 (4.5-29.02; p < 0.001). If the ISSNHL group was used as reference, OR was 55.2 (11.9-253.9; p < 0.001) for the definite MD group, 9.9 (2.1-38.9; p = 0.003) for the recurrent vertigo group, and 5.1 (1.2-21.7; p = 0.03) for the group with fluctuating sensorineural hearing loss. Conclusion: The percentage of patients with EH varies between groups. It is minimal in the ISSNHL group and increases in groups with increasing fluctuating audiovestibular symptoms, with a rate of severe EH similar to the known rate of progression to definite MD in those groups, suggesting that presence of EH by MRI could be related to the risk of progression to definite MD. Thus, EH imaging in these patients is recommended.

Cerebellar ataxia with neuropathy and vestibular areflexia syndrome (CANVAS) is a recently described slowly progressive ataxia with severe imbalance due to the compromise of three of the four sensory inputs for balance, leaving only vision unaffected. Bilateral vestibulopathy is present but saccular and utricular function, measured by vestibular evoked myogenic potentials (VEMPs), has not been widely studied in these patients. Dysautonomia has been reported but is not among the diagnostic criteria. We performed a database analysis to identify patients evaluated between 2003 and 2019 with probable diagnosis of CANVAS by using key words "bilateral vestibulopathy and/or cerebellar ataxia and/or sensory polyneuropathy." Five out of 842 met all conditions. Patients underwent neurological/neurootological exam, brain MRI, visually enhanced vestibulo-ocular reflex (VVOR) exam by high-speed video-oculography using video-Head Impulse Test (vHIT), VEMPs, neurophysiological studies, and genetic tests to exclude other causes of ataxia. Dysautonomia was addressed by the standardized survey of autonomic symptoms. All patients had clinically definite CANVAS as brain MRI showed vermal cerebellar atrophy, neurophysiological studies showed a sensory neuronopathy pattern (absent sensory action potentials), VVOR was abnormal bilaterally, and genetic tests ruled out other causes of ataxia including SCA 3 and Friedreich ataxia. Patients had at least 3 dysautonomic symptoms, including xerostomia/xerophthalmia (5/5). VEMP results varied among patients, ranging from normal to completely abnormal. We found inconsistent results with VEMPs. The utilization of VEMPs in more CANVAS cases will determine its utility in this syndrome. Dysautonomia may be included in the diagnostic criteria.

Objectives/Hypothesis Characterize the state of vestibular compensation of subjects diagnosed with acute unilateral vestibulopathy (AUV) of peripheral origin according to the temporal organization pattern of the refixation saccades (Perez and Rey (PR) score). Study Design Retrospective cross-sectional study using previously collected clinical data from a tertiary referral center. Methods Following the vestibular compensation criteria defined by Eisenman, we used the video head impulse test as the main vestibular function test and compared the results with other traditional tests: rotatory chair test (ROT), caloric test, videonystagmography, clinical situation (CLIN), and the Dizziness Handicap Inventory (DHI) questionnaire from 28 subjects (17 men, 11 women), average age 60.21 years, who were in a compensated and noncompensated vestibular situation. We used the PR score to measure the differences between the study groups. A cluster was developed to define a cutoff point that objectively distinguishes the vestibular compensation status. Results Significant differences in the PR score were found in the state of vestibular compensation in the ROT test (P = .01), DHI (P = .04), and CLIN (P = .023). The vestibular compensation criteria that groups the original variables (PR-CLUSTER) cutoff point was 55 (P = .019). Conclusions The PR score is a measure of temporal organization of the refixation saccades that enables us to distinguish clearly and objectively the vestibular situation of subjects with AUV. We suggest its clinical application. Level of Evidence NA Laryngoscope, 2020

Objectives: Bilateral vestibulopathy is a clinical syndrome in which laboratory testing plays a crucial diagnostic role. We aimed to establish the frequency of detection of that finding in a tertiary level hospital considering the new methods of laboratory vestibular examination nowadays in use, with respect to the conventional caloric and rotatory chair test approaches. Design: Two similar time periods (5 years) were retrospectively evaluated, and the demographic, clinical data and test results from 4,576 patients were reviewed. In the first period, the diagnosis was based on caloric and rotatory chair tests and, in the second, on the video head impulse test. Results: Of the patients included, 3.77% in the first period and 4.58% in the second met the criteria for bilateral vestibular hypofunction; there was no significant difference between both periods. Conclusions: The functional vestibular evaluation to detect bilateral deficiency makes no significant difference to the number of patients diagnosed with a bilateral vestibulopathy. New diagnostic categories probably depend not only on the availability and accessibility of complete vestibular and visual-vestibular evaluation, but also on recent advances in defining vestibular disorders. Bilateral vestibular hypofunction manifests with very different patterns. Progress in more detailed definition (clinical and laboratory) is needed, in particular when all 6 semicircular canals and both maculae are available for testing.

Background The main sequences used to assess degree of endolymphatic hydrops (EH) are the 3D- inversion-recovery (IR) with real reconstruction and the 3D- fluid-attenuated inversion recovery (FLAIR). Objectives The purpose of this study is to describe and compare both sequences. Material and methods Forty-two consecutive patients diagnosed with probable or definite Menier ' s disease were referred for hydrops MR examination. Vestibular and cochlear EH in both sequences were read by two independent radiologists, unaware of the patient's clinical status. The primary study endpoint was the concordance in the hydrops detection and severity with both imaging sequences. This was assessed using the Cohen's kappa Kappa statistic for disease grading and Pearson X(2)test to test the difference in detection rates of hydrops. Statistical significance was defined as two-sidedp < .05. Results We obtained an excellent overall concordance, with a kappa of 0.821, (p < .001) when comparing hydrops detection. The degree of concordance is higher in vestibular hydrops than in cochlear hydrops. The 3D-IR sequence detected more hydrops than the 3D FLAIR, (62 vs. 39.5%,p < .03). Conclusion The 3D-IR sequence seems to be superior to the 3D-FLAIR for the assessment of EH. Significance:The 3D-IR sequence should be considered as a standalone parameter for a shorter and optimized EH magnetic resonance imaging protocol.

Objective: To investigate the main effects of some testing and analysis variables on clinically quantified visually enhanced vestibulo-ocular reflex (VVOR) and vestibulo-ocular reflex suppression (VORS) results using video head impulse test. Methods: This prospective observational clinical study included 19 healthy participants who underwent the VVOR and VORS tests. The effect of demographic variables, head oscillation frequency, rotation direction, visual acuity and analysis time window width and location of the recorded tests on the quantified results of both VVOR and VORS were evaluated. And specifically, for the VORS test the effect of cognitive reinforcement of the participant during testing was evaluated. Results: A statistically significant difference was observed among the VVOR, non-reinforced VORS, and reinforced VORS tests for mean gain values of 0.91 ± 0.09, 0.6 ± 0.15, and 0.57 ± 0.16, respectively (p < 0.001). The optimized linear mixed-effect model showed a significant influence of frequency on the gain values for the reinforced and non-reinforced VORS tests (p = 0.01 and p = 0.004, respectively). Regarding the gain analysis method, statistically significant differences were found according to the short time interval sample location of the records for the initial location of the VVOR test (p < 0.006) and final location of the reinforced VORS test (p < 0.023). Conclusion: Significant differences were observed in the gain values according to VVOR and VORS testing. Head oscillation frequency is a significant factor that affects the gain values, especially in VORS testing. Moreover, in VORS testing, participant concentration has a significant effect on the test for obtaining suppression gain values. When a short time interval sample is considered for VVOR and VORS testing, intermediate time samples appear the most adequate for both tests. Significance: The quantified visually enhanced vestibulo-ocular reflex (VVOR) and vestibulo-ocular reflex suppression (VORS) tests have recently been added to the assortment of available clinical vestibular tests. However, despite the clinical validity of these quantified tests that appear to be of increasing clinical interest, the effects of most of the clinical testing methods and mathematical variables are not well defined. In this research we describe what are the main collecting and analysis variables that could influence to the VVOR and VORS tests. Specially for VORS test, participant concentration on test tasks will have positive effect on the measured vestibulo-ocular reflex (VOR) suppression.

Objectives: Oscillopsia is a disabling condition for patients with bilateral vestibular hypofunction (BVH). When the vestibulo-ocular reflex is bilaterally impaired, its ability to compensate for rapid head movements must be supported by refixation saccades. The objective of this study is to assess the relationship between saccadic strategies and perceived oscillopsia. Design: To avoid the possibility of bias due to remaining vestibular function, we classified patients into two groups according to their gain values in the video head impulse test. One group comprised patients with extremely low gain (0.2 or below) in both sides, and a control group contained BVH patients with gain between 0.2 and 0.6 bilaterally. Binary logistic regression (BLR) was used to determine the variables predicting oscillopsia. Results: Twenty-nine patients were assigned to the extremely low gain group and 23 to the control group. The BLR model revealed the PR score (saccades synchrony measurement) to be the best predictor of oscillopsia. Receiver operating characteristic analysis determined that the most efficient cutoff point for the probabilities saved with the BLR was 0.518, yielding a sensitivity of 86.6% and specificity of 84.2%. Conclusions: BVH patients with higher PR values (nonsynchronized saccades) were more prone to oscillopsia independent of their gain values. We suggest that the PR score can be considered a useful measurement of compensation.

Objective: To evaluate the effect of artifacts on the impulse and response recordings with the video head impulse test (VHIT) and determine how many stimuli are necessary for obtaining acceptably efficient measurements. Methods: One hundred fifty patients were examined using VHIT and their registries searched for artifacts. We compared several variations of the dataset. The first variation used only samples without artifacts, the second used all samples (with and without artifacts), and the rest used only samples with each type of artifact. We calculated the relative efficiency (RE) of evaluating an increasingly large number of samples (3 to 19 per side) when compared with the complete sample (20 impulses per side). Results: Overshoot was associated with significantly higher speed (p= 0.005), higher duration (p< 0.001) and lower amplitude of the impulses (p= 0.002), and consequent higher saccades' latency (p= 0.035) and lower amplitude (p= 0.025). Loss of track was associated with lower gain (p= 0.035). Blink was associated with a higher number of saccades (p< 0.001), and wrong way was associated with lower saccade latency (p= 0.012). The coefficient of quartile deviation escalated as the number of artifacts of any type rose, indicating an increment of variability. Overshoot increased the probability of the impulse to lay on the outlier range for gain and peak speed. Blink did so for the number of saccades, and wrong way for the saccade amplitude and speed. RE reached a tolerable level of 1.1 at 7 to 10 impulses for all measurements except the PR score. Conclusions: Our results suggest the necessity of removing artifacts after collecting VHIT samples to improve the accuracy and precision of results. Ten impulses are sufficient for achieving acceptable RE for all measurements except the PR score.

Background As described by Dumas, an 80-100 Hz vibration applied to the mastoid produces a horizontal nystagmus, with quick phases beating away from the affected side in patients with unilateral vestibular loss (UVL). Aim/objectives To elucidate the characteristics of skull vibration-induced nystagmus (SVIN) in patients suffering from vestibular neuritis and how these characteristics are related to information provided by the video head impulse test (vHIT). Material and methods Sixty-three patients were enrolled to perform a vHIT to measure the gain in both ears. SVIN was induced with stimulation at 30 Hz, 60 Hz, and 100 Hz. The slow phase velocity (SPV) of the SVIN was measured. Results The SVIN test was positive in 25/63 patients at 30 Hz, 36/63 at 60 Hz and 46/63 at 100 Hz. Mean gain difference between both ears to obtain a positive SVIN at 30 Hz was observed to be 0.38 +/- 0.25, decreasing to 0.35 +/- 0.23 at 60 Hz, and 0.31 +/- 0.24 at 100 Hz (p = .025). We found a significant positive linear correlation between the gain asymmetry measured using horizontal vHIT and SPV in SVIN at 100 Hz. Conclusions and significance There is a close relationship between the difference in the gains of both ears as measured using VHIT and the SPV of the nystagmus induced by SVIN at 100 Hz.

A 52-year-old man presented with left hemifacial spasm (HFS). A magnetic resonance imaging scan showed compression of the left facial nerve at the cerebellopontine angle by a dolichoectatic basilar artery, The neurotological evaluation showed an otolithic deficit, with canalicular preservation and normal hearing. The deficit improved after surgical decompression. No previous report has described the impairment of vestibular function in patients presenting with HFS.

Objectives: To describe the vestibular evoked myogenic potential (VEMP) response to air-conducted sound (ACS) and bone-conducted vibration (BCV) in patients with unilateral definite Meniere's disease (MD), and the contribution to the usual ACS evaluation of the bone-air index (BAI) and interaural asymmetry ratio (IAR) in the diagnosis. Methods: A case-control study was designed. Fifty-one patients (25 men and 26 women) with an average age of 55 years, and 31 healthy volunteers with no history of vertigo and hearing loss, were included. The BAI was used as a new parameter to describe the amplitude of the response. Results: Only n10 latency ACS evoked was significantly longer than in controls. The ACS cVEMP p13-n23 amplitude of the affected ear of patients with MD was lower than in the non-affected ear (p = .023) and the control group (.001). The IAR was significantly higher in patients with MD both for the ACS and for the BCV cVEMP compared to the control group: p = .004 and .001, respectively. Significant differences were found in oVEMP n10-p16 amplitude between ACS and BCV in the patients with MD (p = .002). The BAI in oVEMP showed a significant increase in the affected ear compared to the control group (p = .001). The acoustic stimulus in cVEMP was the only one that showed significant differences in amplitude according to degree of hearing loss (p = .039). Conclusions: The joint use of an acoustic and vibratory stimulus is an interesting option to characterize the results in this group. The BAI provides useful complementary information, and also turns out to give added value to the traditional VEMP assessment by ACS. We recommend its use when Meniere's disease is suspected.

This paper presents a classification and definitions for types of nystagmus and other oscillatory eye movements relevant to evaluation of patients with vestibular and neurological disorders, formulated by the Classification Committee of the Barony Society, to facilitate identification and communication for research and clinical care. Terminology surrounding the numerous attributes and influencing factors necessary to characterize nystagmus are outlined and defined. The classification first organizes the complex nomenclature of nystagmus around phenomenology, while also considering knowledge of anatomy, pathophysiology, and etiology. Nystagmus is distinguished from various other nystagmus-like movements including saccadic intrusions and oscillations.

Objective: This study aimed to evaluate the changes in the VOR gain after intratympanic gentamicin therapy and to correlate them with the mid-term effects on the control of vertigo, in a population of Meniere's disease patients. Study Design: The study design was a prospective "Outcomes research." Setting: Tertiary referral center. Patients: This study included 20 patients with unilateral Meniere's disease refractory to medical therapy for at least 1 year, and treated with an on demand intratympanic gentamicin protocol. Intervention: Therapeutic. Main Outcome Measure: Audiometry, caloric testing, and a vHIT before beginning the protocol were performed. Patients underwent weekly vHIT assessments until a significant gain reduction was observed. Subsequently we performed vHIT tests 1 month after the therapy completion, and then every 3 months for at least 1 year. Results: Complete vertigo control (class A) was achieved in 14 patients at the 12-month follow-up assessment. We observed a significant reduction in VOR gain values at the 3-week follow-up assessment. We found a significant correlation between the 1-month posttreatment ipsilateral hVOR gain and the rate of vertigo recurrence after the first IT gentamicin treatment (p = 0.012; r(2) = 0.400). At the mid-term assessment, 10 patients exhibited a significant partial recovery of the hVOR gain. Conclusions: The delayed effect of intratympanic gentamicin and the subsequent gain restoration are factors that may influence the patients' outcome. The feasibility of the vHIT system makes it a useful tool to monitorize the VOR changes.

Objectives It has been suggested that in Ménière¿s disease (MD) a dissociated result in the caloric test (abnormal result) and video head-impulse test (normal result) probably indicates that hydrops affects the membranous labyrinth in the horizontal semicircular canal (HSC). The hypothesis in this study is that based on endolymphatic hydrops¿ cochleocentric progression, hydrops should also be more severe in the vestibule of these patients than in those for whom both tests are normal. Methods 22 consecutive patients with unilateral definite MD were included and classified as NN if both tests were normal or AN if the caloric test was abnormal. MRI evaluation of endolymphatic hydrops was carried out with a T2-FLAIR sequence performed 4 h after intravenous gadolinium administration. The laterality and degree of vestibular endolymphatic hydrops and the presence or absence of cochlear endolymphatic hydrops were recorded. Demographic data, audiometric and vestibular evoked myogenic potentials were collected, and video head-impulse and caloric tests were performed. Results Patients in both groups (NN and AN) were similar in terms of demographic data and hearing loss. The interaural asymmetry ratio was significantly higher for ocular and cervical VEMP in patients in the AN group. There was a significantly higher degree of hydrops in the vestibule of the affected ear of AN patients (¿2; p = 0.028). Conclusion Significant canal paresis in the caloric test is associated with more sev

PurposeComputerized posturography is the gold standard for balance assessment. Because of the great cost and dimensions of commercial equipments, low-cost and portable devices have been developed and validated, such as RombergLab, a software in open source term which works connected with a low-cost force platform. The objective of this study was to obtain normative posturography data using this software.MethodsA multicentric prospective and descriptive study, with 350 healthy participants, was designed. Static postural stability (measured using the modified clinical test of sensory interaction on balance) was evaluated using the software connected to the force platform. Using the confidence ellipse area (CEA) in each condition, global equilibrium score (GES) was calculated and adjusted for significant variable factors using cluster analysis.ResultsMean (SD) GES was 0.72 (0.22). Age (p<0.01), height (p<0.01) and recruitment center (p<0.05) were found as influence factors for GES. Cluster analysis obtained 16 groups stratified by age and height. GES decreases with age and height (p<0.005). No significant interaction of age nor height was found with GES in these clusters (p>0.05). After correction for height and age, GES was no longer influenced by the recruitment center (p>0.05).ConclusionsWith the introduction of the global equilibrium score values of the present study into the software, we consider RombergLab v1.3 a reference posturography tool for healthy individuals. Further studies are needed for validating it as a suitable instrumented test for screening between healthy and pathologic subjects and its reliability over time for the follow-up of patients.

We present a novel method to characterize the morphology of semicircular canals of the inner ear. Previous experimental works have a common nexus, the human-operator subjectivity. Although these methods are mostly automatic, they rely on a human decision to determine some particular anatomical positions. We implement a systematic analysis where there is no human subjectivity. Our approach is based on a specific magnetic resonance study done in a group of 20 volunteers. From the raw data, the proposed method defines the centerline of all three semicircular canals through a skeletonization process and computes the angle of the functional pair and other geometrical parameters. This approach allows us to assess the inter-operator effect on other methods. From our results, we conclude that, although an average geometry can be defined, the inner ear anatomy cannot be reduced to a single geometry as seen in previous experimental works. We observed a relevant variability of the geometrical parameters in our cohort of volunteers that hinders this usual simplification.

Background: Strong static magnetic fields such as those in an MRI machine can induce sensations of self-motion and nystagmus. The proposed mechanism is a Lorentz force resulting from the interaction between strong static magnetic fields and ionic currents in the inner ear endolymph that causes displacement of the semicircular canal cupulae. Nystagmus persists throughout an individual's exposure to the magnetic field, though its slow-phase velocity partially declines due to adaptation. After leaving the magnetic field an after effect occurs in which the nystagmus and sensations of rotation reverse direction, reflecting the adaptation that occurred while inside the MRI. However, the effects of visual fixation and of head shaking on this early type of vestibular adaptation are unknown. Methods: Three-dimensional infrared video-oculography was performed in six individuals just before, during (5, 20, or 60 min) and after (4, 15, or 20 min) lying supine inside a 7T MRI scanner. Trials began by entering the magnetic field in darkness followed 60 s later, either by light with visual fixation and head still, or by continuous yaw head rotations (2 Hz) in either darkness or light with visual fixation. Subjects were always placed in darkness 10 or 30 s before exiting the bore. In control conditions subjects remained in the dark with the head still for the entire duration. Results: In darkness with head still all subjects developed horizontal nystagmus inside the magnetic field, with slow-phase velocity partially decreasing over time. An after effect followed on exiting the magnet, with nystagmus in the opposite direction. Nystagmus was suppressed during visual fixation; however, after resuming darkness just before exiting the magnet, nystagmus returned with velocity close to the control condition and with a comparable after effect. Similar after effects occurred with continuous yaw head rotations while in the scanner whether in darkness or light. Conclusions: Visual fixation and sustained head shaking either in the dark or with fixation inside a strong static magnetic field have minimal impact on the short-term mechanisms that attempt to null unwanted spontaneous nystagmus when the head is still, so called VOR set-point adaptation. This contrasts with the critical influence of vision and slippage of images on the retina on the dynamic (gain and direction) components of VOR adaptation.

Background Classical posturography techniques have been recently enhanced by the use of different motion tracking devices, but for technical reasons they are not used to track directly the body spatial position of a subject. Objective To describe and clinically evaluate a wireless inertial measurement unit-based mobile system to track body position changes. Methods The developed system used a calculus transformation method using the acceleration data corrected by Kalman and Butterworth filters to output position data. A prospective non-randomized clinical study involving 15 healthy subjects was performed to evaluate the agreement between the confidence ellipse areas synchronously measured by the new developed system and a classical posturography system while performing a modified clinical test of sensory interaction in balance. Results The overall intra-class correlation index was 0.93 (CI 0.89, 0.96). Grouped by conditions, under conditions 1-4, Pearson's correlation was 0.604, 0.78, 0.882, and 0.81, respectively. Conclusion The developed wireless inertial measurement unit-based posturography system was valid for tracking the sway variances in normal subjects under habitual clinical testing conditions. Further studies are needed to validate this system on patients and also under other posture conditions.

Introduction Middle ear application of gentamicin is a common medical treatment for uncontrolled Meniere's disease. The objective of the study was to evaluate the impact of endolymphatic hydrops on inner ear delivery. Methods Perilymph gentamicin concentrations and correlation with endolymphatic hydrops in an animal model were assessed. A group of 24 guinea pigs was submitted to surgical obstruction of the endolymphatic sac and duct of the right ear. Gentamicin was applied either to the right ear's round window niche or through a transtympanic injection. Perilymph specimens were collected at different times. Histologic morphometry was used to evaluate both turn-specific and overall hydrops degree. Results In animals with endolymphatic hydrops, lower concentrations of gentamicin were observed after 20 or 120 minutes of exposure and in both types of administration, when compared to controls. This difference reached statistical significance in the round window niche application group (Mann-Whitney, p = 0,007). A negative correlation between perilymphatic gentamicin concentration and hydrops degree could be observed in both groups, after 120 minutes of exposure (Spearman correlation, round window niche p<0,001; TT p = 0,005). Conclusions The study indicates that the endolymphatic hydrops degree has a negative interference on the delivery of gentamicin into the inner ear following middle ear application.

Background: Visually enhanced vestibulo-ocular reflex (VVOR) is a well-known bedside clinical test to evaluate visuo-vestibular interaction, with clinical applications in patients with neurological and vestibular dysfunctions. Owing to recently developed diagnostic technologies, the possibility to perform an easy and objective measurement of the VVOR has increased, but there is a lack of computational methods designed to obtain an objective VVOR measurement. Objectives: To develop a method for the assessment of the VVOR to obtain a gain value that compares head and eye velocities and to test this method in patients and healthy subjects. Methods: Two computational methods were developed to measure the VVOR test responses: the first method was based on the area under curve of head and eye velocity plots and the second method was based on the slope of the linear regression obtained for head and eye velocity data. VVOR gain and vestibulo-ocular reflex (VOR) gain were analyzed with the data obtained from 35 subjects divided into four groups: healthy (N = 10), unilateral vestibular with vestibular neurectomy (N = 8), bilateral vestibulopathy (N = 12), and cerebellar ataxia, neuropathy, and vestibular areflexia syndrome (CANVAS) (N = 5). Results: Intra-class correlation index for the two developed VVOR analysis methods was 0.99. Statistical differences were obtained by analysis of variance statistical method, comparing the healthy group (VVOR mean gain of 1 +/- 0) with all other groups. The CANVAS group exhibited (VVOR mean gain of 0.4 +/- 0.1) differences when compared to all other groups. VVOR mean gain for the vestibular bilateral group was 0.8 +/- 0.1. VVOR mean gain in the unilateral group was 0.6 +/- 0.1, with a Pearson's correlation of 0.52 obtained when VVOR gain was compared to the VOR gain of the operated side. Conclusion: Two computational methods to measure the gain of VVOR were successfully developed. The VVOR gain values appear to objectively characterize the VVOR alteration observed in CANVAS patients, and also distinguish between healthy subjects and patients with some vestibular disorders.

Patients with inner ear damage associated with bilateral vestibular impairment often ask "how much damage do I have." Although there are presently three clinical methods of measuring semicircular canal vestibular function; electronystagmography (ENG or VENG), rotatory chair and video head-impulse (VHIT) testing; none of these methods provides a method of measuring total vestibular output. Theory suggests that the slow cumulative eye position can be derived from the rotatory chair test by multiplying the high frequency gain by the time constant, or the "GainTc product." In this retrospective study, we compared the GainTc in three groups, 30 normal subjects, 25 patients with surgically induced unilateral vestibular loss, and 24 patients with absent or nearly absent vestibular responses due to gentamicin exposure. We found that the GainTc product correlated better with remaining vestibular function than either the gain or the time constant alone. The fraction of remaining vestibular function was predicted by the equation R=(GainTc/11.3) - 0.6. We suggest that the GainTc product answers the question "how much damage do I have," and is a better measure than other clinical tests of vestibular function.

OBJECTIVES: To measure the auditory (pure tone audiometry and word recognition scores) and vestibular (video head impulse test and vestibular myogenic potentials) outcomes in patients diagnosed with Meniere¿s disease (MD) who underwent cochlear implantation. MATERIAL AND METHODS: This prospective study included 23 cochlear implant users with MD and 29 patients diagnosed with far-advanced oto - sclerosis (the control group). RESULTS: The preoperative mean pure tone average thresholds were 99 and 122.5 dB for the Meniere¿s and control groups, respectively. Word recog- nition scores after cochlear implant yielded a median of 80% and 72% for the Meniere¿s and control groups, respectively. Semicircular canal gain was not observed to vary post implantation (mean variation for lateral, posterior, and anterior plane was 0, 0.03, and 0, respectively). The mean ocular and cervical myogenic potentials asymmetry varied as 9.65% and 18.39%, respectively. CONCLUSIONS: The auditory performance improved in patients with MD similar to the general cochlear implant population. No major dysfunction of otolithic or semicircular canal function was demonstrated after the implantation surgery

ObjectiveMethodsTo assess whether there are differences in vestibulo-ocular reflex (VOR) gain for suppression head impulse (SHIMP) and head impulse (HIMP) video head impulse test paradigms, and if so, what are their causes. Prospective multicenter observational double-blind nonrandomized clinical study was performed by collecting 80 healthy subjects from four reference hospitals. SHIMP data was postprocessed to eliminate impulses in which early SHIMP saccades were detected. Differences between HIMP and SHIMP VOR gain values were statistically evaluated. Head impulse maximum velocity, gender, age, direction of impulse, and hospital center were considered as possible influential factors. ResultsConclusionA small significant statistical difference between HIMP and SHIMP VOR gain values was found on repeated measures analysis of variance (-0.050.006, P<0.001). Optimized linear model showed a significant influence of age variable on the observed differences for HIMP and SHIMP gain values and did not find influence between gain values differences and maximum head impulse velocity. Both HIMP and SHIMP VOR gain values were significant lower (-0.09, P<0.001) when the impulses were performed to the left side. We had observed a difference in SHIMP and HIMP gain values not adequately explained by known gain modification factors. The persistence of this slight but significant difference indicates that there are more factors causing lower SHIMP VOR gain values. This difference must to be considered in further studies as well as in the clinical SHIMP testing protocols. We hypothesized that VOR phasic response inhibition could be the underlying cause of this difference. Level of Evidence2b. Laryngoscope, 128:2383-2389, 2018

Isolated acute vestibular syndrome remains a diagnostic challenge in the emergency department and the initial approach should include the identification of a central or peripheral etiology. This is the case report of an elderly patient with known cardiovascular risk factors presenting with acute vertigo and unsteadiness. Neurological examination was notable only for down-beat nystagmus and diffusion-weighted MRI showed normal findings. He was treated as having an emerging anterior-inferior cerebellar artery (AICA) stroke. Even when MRI showed no signs of hemorrhage or infarction, the neurotological bedside examination was a determinant. The cochleovestibular system was not spared by the ischemic injury but a more extensive neurological damage was probably avoided by approaching this case as a stroke.

Objective: Compare the caloric vestibular test (CVT) and the video head impulse test (vHIT) in the evaluation of Meniere's disease (MD) and to analyze their diagnostic accuracy. Materials and methods: Retrospective review of CVT and vHIT performed in MD patients at a tertiary care referral center in Spain. Results: A total of 88 patients were reviewed. The CVT was abnormal in 67% (n=59) of patients, while the vHIT was abnormal in 66% (n=58) of them. Agreement between both tests was poor, regardless of whether the horizontal semicircular canal (SCC) or all SCC were analyzed (kappa=.21). Anterior SCC pathology was found in 30% (n=27) of the subjects while 51% (n=45) had altered gains in the posterior SCC. Conclusions: Our study shows that patients with MD can have functional deficit involving the vertical semicircular canals, which cannot be detected by the CVT alone. Therefore, both tests should be used in a complementary fashion.

Temperature maps, vorticity, and velocity fields were successfully obtained to characterize the endolymphatic flow during the caloric test in the developed models. In the normal semicircular canal, a well-defined endolymphatic linear flow was obtained, this flow has an opposite direction depending only on the cooling or warming condition of the simulation. For the hydropic model a non-effective endolymphatic flow was predicted; in this model the velocity and vorticity fields show a non-linear flow, with some vortices formed inside the hydropic duct.

Background. False negative fistula testing in patients with chronic suppurative otitis media is a dilemmawhen proceeding to surgery. It is imperative to rule out a dead labyrinth or a mass effect secondary to the cholesteatoma in an otherwise normally functioning inner ear. We present a case series of three patients in whoma bedside vestibuloocular reflex (VOR) evaluation using a head impulse test was used successfully for further evaluation prior to surgery. Results. In all three cases with a false negative fistula test we were able to further evaluate at the bedside and were not only able to register the abnormal VOR but also localize its deterioration to a particular semicircular canal eroded by the fistula. Conclusion. Vestibuloocular reflex evaluation is mandatory in patients with suspected labyrinthine fistula due to cholesteatoma of the middle ear before proceeding to surgery. We demonstrate successful use of a bedside head impulse test for further evaluation prior to surgery in patients with false negative fistula test.

Isolated vestibule-lateral semicircular canal dysplasia (LSCCD) is one of the most common inner ear malformations. We present a case of a 59-year-old patient with right vestibule-lateral canal dysplasia and a history of spontaneous vertigo spells without hearing loss. Vestibular assessment showed a dissociation between caloric responses and vestibulo-ocular reflex gain as measured with the video head-impulse test.

Cluster analysis defines clinical subgroups in MD, and it extends the phenotype beyond audiovestibular symptoms. This classification will help to improve the phenotyping in MD and facilitate the selection of patients for randomised clinical trials

In 2013, a 70-year-old male was admitted with an acute episode of vertigo, nausea, and vomiting with duration of one day. The patient's background included prehypertension, vitiligo, left ventricular hypertrophy, and Sjögren's syndrome. He denied any previous episode of vertigo or migraine manifestations. Neither hearing loss nor tinnitus or otorrhea was detected at the time of evaluation. No neurological symptoms were found. There was a left-beating spontaneous nystagmus Grade 3. The patient could stand still and walk on his own with some help without falling. Day 1 vHIT showed a significant reduction in VOR gain and refixation saccades after head impulses were delivered in the planes of the right anterior and horizontal semicircular canals. MRI showed no significant findings. He was treated with steroids. A vHIT performed 14 days later showed recovery of gains and no refixation saccades. In 2015, the patient had a new episode of acute vertigo. The clinical examination was similar, and the vHIT revealed a new drop of right superior and lateral canal gains. Cervical and ocular VEMPs were performed, and no significant asymmetry was detected. Serum PCR for herpes viruses resulted negative. Contrast MRI was performed without relevant brain findings.

The area of stability among patients shows a reduction to 35-62% of the expected total. That reduction was not found to be dependent on age. CONCLUSION: There is a symmetric reduction in the limits of stability (LOS) in patients with unilateral vestibulopathy who suffer chronic instability. None of the areas measured were correlated with the composite score of the sensory organization test and, as such, must be considered as an adjunct measure to characterize the postural limitations in those patients.

Objective: To evaluate vestibular compensation via measurement of the vestibulo-ocular reflex (VOR) following vestibular schwannoma surgery and its relationship with changes in saccades strategy after surgery. Patients: Thirty-six consecutive patients with vestibular schwannomas, without brain-stem compression, underwent surgical resection. Patients were recruited from University Hospital of Salamanca, Spain. Methods: We assessed the age, sex, tumor size, degree of canalicular weakness, and preoperative video head impulse test (gain and saccade organization measured with PR score). Gain and saccade organization were compared with postoperative values at discharge and also at 1, 3, and 6 months. PR scores are a measure of the scatter of refixation saccades. Results: Patients with normal preoperative caloric function had higher PR scores (saccades were scattered) following surgery compared to patients with significant preoperative canal paresis (p < 0.05). VOR gain and the presence of covert/overt saccades preoperatively did not influence the PR score (p > 0.05), but a group of patients with very low VOR gain (< 0.45) and covert/overt saccades before surgery had lower PR scores after surgery. The differences after 6 months were not significant. Conclusion: Patients with more severe vestibular dysfunction before vestibular schwannoma surgery show significantly faster vestibular compensation following surgery, manifested by changes in VOR gain and PR score. The scatter of compensatory saccades (as measured by the PR score) may be a surrogate early marker of clinical recovery, given its relationship to the Dizziness Handicap Inventory.

CONCLUSION: VOR adaptation and organization of refixation saccades in a gathered pattern is a process that can be artificially induced in patients with unilateral vestibular loss who have not developed it naturally, improving imbalance and vestibular disability. OBJECTIVE: To test that temporary grouping of refixation saccades should be linked to better clinical status without gain recovery. METHODS: A training to induce the refixation saccades into gathered fashion is performed. The outcome measures are handicap level measured by the dizziness handicap index (DHI) and refixation saccades organization pattern measured by a numeric score called 'PR' given by a software developed by the authors. Analysis is done before the training and 1 and 3 months after ending, Non-parametric tests were used for statistical analysis. RESULTS: This study has included 10 healthy subjects (four males, six females), and 16 patients with chronic unsteadiness due to unilateral vestibular loss (nine vestibular neuritis, four post-surgical vestibular schwannoma, and three cases after intra-tympanic gentamycin in patients with Ménière's disease). The reduction in the DHI score was significant at 1 (p¿=¿0.028) and 3 months (p¿=¿0.042) post-treatment. Also, statistically significant differences were found between the PR score before and PR score 1 (p¿=¿0.005) and 3 months after the treatment (p¿=¿0.003).

OBJECTIVES: This study aimed to evaluate the results of the video head impulse test and of the caloric and rotatory chair tests in patients with dizziness. Agreement between test results was assessed and the best protocol for detecting peripheral vestibulopathy was identified. METHODS: Participants comprised 116 patients, 75 with a peripheral vestibulopathy and 41 with non-peripheral vestibulopathy. The main outcome measures were classified as normal or abnormal according to our laboratory data. RESULTS: Agreement between tests was low. Vestibulopathy testing that required all three results to be abnormal had a sensitivity of 0.547, a specificity of 0.878, and positive and negative predictive values of 0.891 and 0.514, respectively. Vestibulopathy testing that required just one result to be abnormal had a sensitivity of 0.933, a specificity of 0.292, and positive and negative predictive values of 0.701 and 0.705, respectively. CONCLUSION: In peripheral vestibulopathy, there was weak concordance in the assessment of horizontal semicircular canal function among the different tests. However, the video head impulse test had sufficient statistical power to be recommended as the first-line test.

En nuestro paciente no había evidencia de trastorno neurológico subyacente, incluso en la RM, y suponemos que el NAP surgió debido a una disfunción de los mecanismos centrales de la estabilización y de la deficiencia del input y la fijación visual, originados por sus antecedentes oftalmológicos. Otro punto de interés en nuestro caso fue la asimetría del nistagmo, probablemente debida al input visual (deficiencia de agudeza visual en el ojo izquierdo), lo que sugiere que el RVO izquierdo puede ser más relativamente inestable que el derecho. Se había postulado que la pérdida visual unilateral no causa por sí misma el NAP7, y en nuestro caso no ha sido demostrado. Sin embargo, el NAP se eliminó tras la última cirugía oftalmológica con éxito.

Excellent concordance between RombergLab and clinical approved force platform was obtained (intra-class correlation coefficient =0.94). A Bland and Altman graphic concordance plot was also obtained. The source code used to develop RombergLab was published in open source terms.

The aim of this paper is to present for the first time the functional evaluation of each of the vestibular receptors in the six semicircular canals in a patient diagnosed with Meniere's disease during an acute attack. A 54-year-old lady was diagnosed with left Meniere's disease who during her regular clinic review suffers an acute attack of vertigo, with fullness and an increase of tinnitus in her left ear. Spontaneous nystagmus and the results in the video head-impulse test (vHIT) are shown before, during, and after the attack. Nystagmus was initially left beating and a few minutes later an upbeat component was added. No skew deviation was observed. A decrease in the gain of the vestibuloocular reflex (VOR) and the presence of overt saccades were observed when the stimuli were in the plane of the left superior semicircular canal. At the end of the crisis nystagmus decreased and vestibuloocular reflex returned to almost normal. A review of the different possibilities to explain these findings points to a hypothetical utricular damage.

CONCLUSION: The application described in this study appears to be accurate and valid, thus allowing calculation of a hearing handicap and assessment of the pure-tone air conduction threshold with iPhone/iPad devices. OBJECTIVE: To develop and evaluate a newly developed professional, computer-based hearing handicap calculator and a manual hearing sensitivity assessment test for the iPhone and iPad (AudCal). METHODS: Multi-center prospective non-randomized validation study. One hundred and ten consecutive adult participants underwent two hearing evaluations, a standard audiometry and a pure-tone air conduction test using AudCal with an iOS device. The hearing handicap calculation accuracy was evaluated comparing AudCal vs a web-based calculator. RESULTS: Hearing loss was found in 83 and 84 out of 220 standard audiometries and AudCal hearing tests (Cohen's Kappa = 0.89). The mean difference between AudCal and standard audiogram thresholds was -0.21 ± 6.38 dB HL. Excellent reliability and concordance between standard audiometry and the application's hearing loss assessment test were obtained (Cronbach's alpha = 0.96; intra-class correlation coefficient = 0.93). AudCal vs a web-based calculator were perfectly correlated (Pearson's r = 1).

CONCLUSION: The effect of visual condition is more intense in the first trial response in normal subjects and patients and in last trial response only in patients. The first trial effect is more evident in compensated patients in the eyes open condition with any type of perturbation, and in non-compensated patients with the angular displacements in either visual condition. OBJECTIVE: The study of body reaction to FTR can help to understand the complex mechanisms involved in the postural response and to develop new therapies to improve stability and prevent falls in unilateral vestibular deficit (UVD). This work describes the adaptation effect and the visual influence on the postural response to repetitive balance perturbation stimulus in normal subjects, compensated, and uncompensated UVD patients. METHODS: The magnitude of displacement has been measured when the support surface is linearly or angularly displaced. The differences between results in the first and late trial, and the differences between the eyes open and eyes closed situation have been compared. RESULTS: Compensated patients recover the adaptation ability to unexpected changes on the support surface through visual preference mechanism. Not compensated patients present hypermetric postural response with greater instability in the eyes open and eyes closed situations.

CONCLUSION: The developed software (HITCal) may be a useful tool in the analysis and measurement of the saccadic video head impulse test (vHIT) responses and with the experience obtained during its use the authors suggest that HITCal is an excellent method for enhanced exploration of vHIT outputs. OBJECTIVE: To develop a (software) method to analyze and explore the vHIT responses, mainly saccades. METHODS: HITCal was written using a computational development program; the function to access a vHIT file was programmed; extended head impulse exploration and measurement tools were created and an automated saccade analysis was developed using an experimental algorithm. For pre-release HITCal laboratory tests, a database of head impulse tests (HITs) was created with the data collected retrospectively in three reference centers. This HITs database was evaluated by humans and was also computed with HITCal. RESULTS: The authors have successfully built HITCal and it has been released as open source software; the developed software was fully operative and all the proposed characteristics were incorporated in the released version. The automated saccades algorithm implemented in HITCal has good concordance with the assessment by human observers (Cohen's kappa coefficient = 0.7).

CONCLUSION: Patients with cochlear implants should be treated no differently than non-implanted patients with similar symptomatology. OBJECTIVES: To describe the spectrum of symptomatology, treatment, and long-term follow-up of patients with cochlear implant and vestibular complaints. METHODS: This retrospective study included 25 patients with late onset vestibular complaints (more than 1 month post-implantation). Each patient underwent an extensive interrogatory and physical exam with ancillary test to complete a diagnosis. Treatment was given according to this and all patients followed a vestibular rehabilitation program. RESULTS: The total population was 72% male and 28% female, median age was 58 years; minimal follow-up was 9 months (mean = 51, median = 34). Cochleostomy was performed in eight cases and round window insertion was performed in 19 (two patients were removed from each group in the analysis due to their bilateral implantation under a different approach). The mean time from implant to vestibular symptoms was 53 months, median = 32; a Kaplan Meier graphic showed the round window approach has faster onset of symptoms with statistical significance (p = 0.020). The most common complaint was instability in all patients and after both surgical approaches. No difference in symptoms was found with a Kruskall Wallis test except for vertigo spells (more common in the round window approach). In 12 patients the symptomatology was attributed to the implanted side. In the long-term follow-up a relatively high number of patients (20/25) recovered with standard treatment, suggesting the presence of the implant is not associated with poor recovery prognosis.

OBJECTIVE: To characterize the response in the video head-impulse test for the assessment of the vestibulo-ocular reflex (VOR) in patients because of vertigo and dizziness. MATERIALS AND METHODS: After rightward and leftward head impulses, the following results evaluated were: gain of the reflex and appearance of refixation saccades. A particular type of response (normal gain VOR and refixation saccades) was evaluated in a group of patients. RESULTS: In patients with a unilateral abnormality consisting of normal gain and refixation saccades, there was a close concordance with the diseased side and the side to which head impulses elicited the abnormal result. CONCLUSION: In the assessment of patients with dizziness, finding a normal gain VOR with refixation saccades indicates the existence of a peripheral vestibulopathy and localizes to the side of the lesion.

OBJECTIVE: To analyze vestibulo-ocular responses using the video head impulse test in the yaw axis. STUDY DESIGN: Prospective. SETTING: Tertiary and university hospital. PATIENTS: Two hundred twelve healthy subjects with no history of vestibular or neurologic impairment. INTERVENTION: Video head impulse test in the lateral semicircular canal plane. MAIN OUTCOME MEASURES: Vestibulo-ocular reflex (VOR) gain and appearance of refixation saccades (RSs) considering sex, age, and head impulse velocity and direction. RESULTS: Mean gain was 1.06 ± 0.07, and there were no differences between sexes. For all the impulses (n = 9,654; 4,947 rightward and 4,707 leftward), VOR gain decreased as head impulse velocity increased. When gain was evaluated by age and head velocity, it was steady until age 70 years for higher-velocity impulses and until age 90 years for lower-velocity head impulses. RSs were detected in 52 subjects, occurring after impulses to both sides of the head in 22 of these subjects. The number of subjects with RSs was significantly higher after age 71 years, and velocity was correlated, not with age, but with head impulse velocity. CONCLUSION: VOR gain was stable until age 90 years and thereafter dropped. However, this decrease occurred progressively in younger subjects as head impulse velocity increased, with VOR gain for faster head impulses decreasing significantly in subjects older than 70 years. This finding, in addition to the appearance of RSs, can be explained by the effect of aging on the deterioration of the vestibular system in the semicircular canals.

OBJECTIVE: Assess angular vestibular-ocular reflex (VOR) changes after treatment with intratympanic gentamicin (ITG) for Ménière's disease (MD) and impact on short-term follow-up. DESIGN: Prospective study. METHODS: Patients submitted to ITG for unilateral MD. The gain VOR and the presence of compensatory saccades elicited by rapid head impulses were measured using the video head impulse test (vHIT). RESULTS: The study included 31 subjects (mean age: 59 years). Functional Level Scale (FLS) distributions were 35,5% (FLS3); 32,2% (FLS4); and 32,2% (FLS5). Mean follow-up was 21¿±¿7 months. Multiple injections were needed in nine patients. VOR gain in the treated ear was significantly reduced in all subjects and for all the semicircular canals (paired samples t test; P¿<¿0,05). Gain averages after treatment were 0,61 (superior); 0,69 (horizontal); and 0,47 (posterior). A horizontal canal VOR gain superior to 0,80 after treatment was associated with the need for a second gentamicin injection (Chi-square; P¿=¿0,003). Gain asymmetry between the symptomatic and asymptomatic ear (GASM) was increased after treatment. The rate of vestibular function reduction was 47,9%; 26,0%; and 35,8% for the superior, horizontal, and posterior canals, respectively. According to the receiving operator characteristic curve, the amount of change in GASM must be greater than 7 in order to predict the avoidance of a second procedure (area under the curve [AUC] horizontal canal¿=¿0,861) and the amount of vestibular function reduction in the pathologic ear in patients with a controlled disease must be greater than 17,8% (AUC horizontal canal¿=¿0,843). CONCLUSIONS: When evaluated with the vHIT, intratympanic gentamicin changes in VOR seem to foresee short-term control of vertigo attacks. LEVEL OF EVIDENCE: 4. Laryngoscope, 125:1915-1920, 2015.

Conclusion: The low clinical efficacy of the treatment for patients included in this work correlates with no noticeable effect on the vestibular function. Objective: To assess follow-up in patients with idiopathic and secondary Ménières disease after treatment with intra-tympanic dexamethasone and correlate clinical findings with changes in the vestibular-ocular reflex elicited after stimulation of each of the six semicircular canals. Methods: This is a single center retrospective review of patients presenting the clinical symptomatology of Meniérès disease treated with intra-tympanic dexamethasone. An audiometric evaluation was performed in each patient before and after treatment. The study cohort was divided into two groups: those evaluated after a short period of time and after a long period of time. Results: The study included 30 patients, mean age = 61 years. Differences in mean pure-tone average before and after treatment were non-significant for both treated (0.61 dB, p = 0.723) and untreated (0.59 dB, p = 0.609) ears. Vestibular-ocular reflex gain averages in the treated ear after treatment were 0.73 (superior semicircular canal), 0.86 (horizontal semicircular canal), and 0.69 (posterior semicircular canal). The gain did not vary significantly in the Superior (p = 0.194), the Horizontal (p = 0.646), or the Posterior Semicircular Canal (p = 0.820). Similar were obtained for the untreated ear.

Introduction: Dizziness is a frequent complaint in patients with vestibular schwannoma (VS). An abnormal vestibulo-ocular reflex (VOR) can explain this dizziness in patients with VS. The video Head impulse test (vHIT) offers a chance to describe specifically the VOR findings in such patients. Study Design: Retrospective cases series study in a tertiary referral hospital. Methods: Fifty consecutive patients with VS were classified in accordance with the morphology of the VOR; gain, covert saccade, and overt saccade were analyzed both in the affected side and in the healthy side. For all patients, caloric tests were performed. All patients were tested before surgery. Results: Caloric response was normal in 31 of 50 patients. The video Head impulse test was abnormal in 45 of 50 patients. For the affected side, low horizontal VOR gain was found in 27 of 50 patients, covert saccade was observed in 37 of 50, and overt saccade was observed in 26 of 50. In the healthy side, vHIT was abnormal in 29 of 50 patients, with a low gain in four of 50, covert saccade in seven of 50, and overt saccade in 23 of 50. In VS, gain for the affected side is not associated with caloric response, but gain for the affected side is associated with gain in the healthy side. Covert and overt saccade for the affected side is associated with gain for the affected side. In the healthy side, overt saccade is associated with low gain for the affected side. Conclusions: Video head impulse test improves the vestibular testing before surgery in patients with VS and should be included in the usual clinical tests for these patients.

Primary objective of this study was to find a statistical link between the most worldwide comorbidities affecting the elderly population (hypertension, diabetes, osteoarthrosis, osteoporosis and depression) and recurrent episodes of BPPV. Secondary objective was defining possible "groups of risk" for people suffering recurrent positional vertigo related to the presence of a well documented comorbidity. METHODS: This was an observational, cross-sectional, multicenter, spontaneous, non-pharmacological study. The data of 1092 patients suffering BPPV evaluated in 11 different Departments of Otolaryngology, Otoneurology and Neurology, referring Centers for positional vertigo evaluation, were retrospectively collected. RESULTS: Regarding evaluated comorbidities (hypertension, diabetes, osteoarthrosis, osteoporosis and depression), data analysis showed the presence of at least one comorbid disorder in 216 subjects (19.8%) and 2 or more in 408 subjects (37.4%). Moreover there was a statistical significant difference between the number of comorbidities and the number of recurrences, otherwise said as comorbidity disorders increased the number of relapses increased too. CONCLUSION: The presence of a systemic disease may worsen the status of the posterior labyrinth causing a more frequent otolith detachment. This condition increases the risk for patients suffering BPPV to have recurrent episodes, even if correctly managed by repositioning maneuvers. The combination of two or more of aforementioned comorbidities further increases the risk of relapsing BPPV, worsened by the presence of osteoporosis. On the basis of this results it was possible to define "groups of risk" useful for predicting BPPV recurrence in patients with one or more comorbidity.

Hypothesis: Evaluate, based on morphologic and histologic parameters, the atraumaticity of 2 electrode arrays implanted in 10 human temporal bones. Background: Atraumatic surgery and electrode arrays are current topics in otologic surgery. The preservation of cochlear anatomy and its functions is a priority and morphologic evaluation of the surgical trauma is essential to continue improving in this field. Methods: Ten preserved human temporal bones (TB) without anatomic alterations were used in this study. They were divided into 2 groups of 5, and atraumatic surgery was performed to insert HiFocus 1J (group A) and HiFocus Helix (group B) electrode arrays. Anatomic comparisons were performed using computed tomography and histologic analysis. Results: Group A: the mean length for the cochlear longitudinal axis was 10.30 mm, and the cochlear transversal axis was 7.2 mm. Scala tympani insertion was achieved in 4/5 TB studied, with a mean depth and angle of insertion of 19.2 mm and 325.5°, respectively. Lateral location of the electrode array was achieved in all specimens. No significant correlation was observed between these dimensions and depth of insertion. Group B: the mean length for the cochlear longitudinal axis was 9.52 mm, and cochlear transversal axis was 6.38 mm. Scala tympani insertion was achieved in 4/5 TB studied, with a mean depth and angle of insertion of 17.5 mm and 352°, respectively. Modiolar location of the electrode array was achieved in all specimens. A positive correlation was established between the linear and angular insertion depths (p = 0.044). Conclusion: In summary, it is safe to state that neither electrode array shows significant insertion trauma.

HYPOTHESIS: Evaluate, based on morphologic and histologic parameters, the atraumaticity of 2 electrode arrays implanted in 10 human temporal bones. BACKGROUND: Atraumatic surgery and electrode arrays are current topics in otologic surgery. The preservation of cochlear anatomy and its functions is a priority and morphologic evaluation of the surgical trauma is essential to continue improving in this field. METHODS: Ten preserved human temporal bones (TB) without anatomic alterations were used in this study. They were divided into 2 groups of 5, and atraumatic surgery was performed to insert HiFocus 1J (group A) and HiFocus Helix (group B) electrode arrays. Anatomic comparisons were performed using computed tomography and histologic analysis. RESULTS: Group A: the mean length for the cochlear longitudinal axis was 10.30 mm, and the cochlear transversal axis was 7.2 mm. Scala tympani insertion was achieved in 4/5 TB studied, with a mean depth and angle of insertion of 19.2 mm and 325.5°, respectively. Lateral location of the electrode array was achieved in all specimens. No significant correlation was observed between these dimensions and depth of insertion. Group B: the mean length for the cochlear longitudinal axis was 9.52 mm, and cochlear transversal axis was 6.38 mm. Scala tympani insertion was achieved in 4/5 TB studied, with a mean depth and angle of insertion of 17.5 mm and 352°, respectively. Modiolar location of the electrode array was achieved in all specimens. A positive correlation was established between the linear and angular insertion depths (p = 0.044). CONCLUSION: In summary, it is safe to state that neither electrode array shows significant insertion trauma.

Meniere's disease is an episodic vestibular syndrome associated with sensorineural hearing loss (SNHL) and tinnitus. Patients with MD have an elevated prevalence of several autoimmune diseases (rheumatoid arthritis, systemic lupus erythematosus, ankylosing spondylitis and psoriasis), which suggests a shared autoimmune background. Functional variants of several genes involved in the NF-¿B pathway, such as REL, TNFAIP3, NFKB1 and TNIP1, have been associated with two or more immune-mediated diseases and allelic variations in the TLR10 gene may influence bilateral affectation and clinical course in MD. We have genotyped 716 cases of MD and 1628 controls by using the ImmunoChip, a high-density genotyping array containing 186 autoimmune loci, to explore the association of immune system related-loci with sporadic MD. Although no single nucleotide polymorphism (SNP) reached a genome-wide significant association (p<10(-8)), we selected allelic variants in the NF-kB pathway for further analyses to evaluate the impact of these SNPs in the clinical outcome of MD in our cohort. None of the selected SNPs increased susceptibility for MD in patients with uni or bilateral SNHL. However, two potential regulatory variants in the NFKB1 gene (rs3774937 and rs4648011) were associated with a faster hearing loss progression in patients with unilateral SNHL. So, individuals with unilateral MD carrying the C allele in rs3774937 or G allele in rs4648011 had a shorter mean time to reach hearing stage 3

The differential diagnosis of patients with acute unilateral vestibulopathy rests in the proper clinical assessment and use of selected tests of vestibular function. In case of a central nervous system lesion as in Multiple Sclerosis, the case shown here, it is of particular importance to observe congruency between severity of symptoms and signs and, of topographic diagnosis. We report a case of a 37-year-old woman with recent onset disequilibrium that after careful analysis of the different test results several incongruences were found; this prompted a radiological study that provided the clue to diagnosis. After treatment the patient recovered completely not only clinically but also in vestibular deficit.

CONCLUSIONS: The presence of orthotropic nystagmus (ON), in multiple positions, appears to predict the success of canalith repositioning maneuvers (CRMs). In this sense CRMs under video-Frenzel are informative for the immediate follow-up, although not related to the degree of disability or emotional distress. Still, attention should be given to psychological assistance even in cases of clinically cured benign paroxysmal positional vertigo (BPPV). OBJECTIVE: The aim of the study was to highlight the prognostic value of nystagmus in CRMs for BPPV and its relevance for emotional and patient-perceived disability. METHODS: A group of 57 patients were selected from 3 balance disorders centers. CRMs were performed under video-Frenzel control. Assessment of patient disability and positional nystagmus was performed 2 months later. Emotional (Cuestionario de Impacto Emocional del Vértigo, CIEV) and quality of life (Dizziness Handicap Inventory, DHI) impact were evaluated. RESULTS: The posterior semicircular canal (SCC) was affected in 84.2% of cases, the horizontal SCC in 10.5%, and the anterior SCC in 5.1%. Appropriate CRMs were performed. ON was present in 67% of cases. Overall resolution after the first treatment was achieved in 56% of cases. With ON present the success rate was 63% and when not observed the rate was 42%. DHI or CIEV scores were not significantly different when comparing the presence vs absence of ON. In nine patients (16%) an abnormal CIEV score was observed after treatment, even though a cured status was achieved in six of these nine patients.

OBJECTIVE: The caloric test and the video head-impulse test are diagnostic tools that examine the function of the horizontal semicircular canal. There are major differences between the two tests. These are stimulus characteristics, methodology, and function examined. MATERIALS and METHODS: This is a prospective work in 123 patients with different types of vestibular disease seen because of dizziness in which both procedures were performed the same day. First, the spontaneous nystagmus and head-shake nystagmus were measured. The video head-impulse test was carried out, and finally, the caloric test was performed with water at two different temperatures. Both ears were irrigated alternately. Main outcome measures were the canal paresis in the caloric test and gain of vestibulo-ocular reflex, gain asymmetry, and refixation saccades in the vHIT. RESULTS: The caloric test and the vHIT results were fully coincident in 60 patients (48.7%), and the results for both were normal in 36 patients. Discrepancies were found in 3 patients regarding the deficient side, and in 14 patients, an added contralateral (according to the caloric test) abnormal result was obtained. In 46 patients, one of the tests was normal while the other was not, but both were in accordance with the diseased side. The correlation coefficient for canal paresis and gain asymmetry was 0.67, and the agreement was low: kappa=0.252. CONCLUSION: The assessment of horizontal semicircular canal function with the vHIT needs to take into consideration not only the gain in VOR but also the existence of refixation saccades. The information from both methods is redundant in some cases but complementary in most, and the existence of discrepancies is very low.

Long-term follow-up after vestibular schwannoma surgery has shown that 22% of the patients display a particular abnormality in the VOR because refixation saccades occur in a random fashion after elicitation of the reflex in the HIT test. These patients report the higher level of vestibular disability and handicap

Abstract Conclusion: The distribution of abnormal results is not uniform between different canals in each patient; the most frequent gain reduction is obtained for the posterior canal. Gain reduction reflects the disease duration and amount of hearing loss. OBJECTIVE: To test the hypothesis that the vestibulo-ocular reflex (VOR) evoked after stimulation of each semicircular canal behaves in a different manner in patients with unilateral definite Ménière's disease. METHODS: We studied the VOR evoked by rapid head-impulses in the plane of the 6 semicircular canals in 36 patients. It was evaluated with a video system that analyzes the head and eye velocity and the gain was the objective measure. RESULTS: In 12 (33.3%) patients the examination of both ears was normal for all the semicircular canals, in 12 patients the results from the affected ear were abnormal in at least 1 of the semicircular canals, in 11 (30.5%) patients the results were abnormal in at least 1 of the semicircular canals in both the affected and unaffected ears, and in 1 (2.9%) patient the results were abnormal only in the unaffected ear. The most frequent abnormal result was obtained from the posterior canal of the affected ear and from the coupled superior canal of the unaffected ear. The distribution of abnormal findings was dependent on the disease duration and hearing loss.

The mean gain of VOR was within normal limits for the six semicircular canals and there were no significant differences between the same canals on each side of patients with BPPV in whom canalolithiasis was located in the SSC. However, gain asymmetry was different for each pair of canals.

Toll-like receptors trigger the innate immune response by activating various cell types such us macrophages and lymphocytes. We genotyped SNV of TLR3, TRL7, TLR8 and TLR10 in 863 Spanish and 150 Italian patients with Meniere's disease (MD) and 1,013 controls by using Taqman assays. Real-Time qPCR was used to measure the expression level of TLR10 in peripheral blood leukocytes. The overall dataset showed that the C allele and the CC genotype of rs11096955 in TLR10 gene were more commonly observed in controls than patients (corrected p¿=¿1¿×¿10(-3), OR¿=¿0.68 [95 % confidence interval, 0.54-0.84] for CC genotype; corrected p¿=¿1.5¿×¿10(-5), OR¿=¿0.75 [0.66-0.85] for allele C). Moreover, the CC genotype was more frequent in patients with uni- (19 %) than bilateral sensorineural hearing loss (SNHL) (13 %). Logistic regression demonstrated that the time since the onset of MD, Tumarkin crises, hearing stage and rs11096955 were independent factors influencing the risk of bilateral SNHL. In addition, rs11096955 influenced hearing loss progression in patients with bilateral MD. No change in expression of TLR10 was observed according to CC, CA or AA genotypes. Our data suggest that allelic variants of TLR10 gene may influence the susceptibility and time-course of hearing loss of MD in the European population.

The aims of this study were to estimate the prevalence of familial cases in patients with Meniere's disease (MD) and to identify clinical differences between sporadic and familial MD. We recruited 1375 patients with definite MD according to the American Academy of Otolaryngology-Head and Neck Surgery criteria, obtaining the familial history of hearing loss or episodic vertigo by direct interview or a postal survey in 1245 cases in a multicenter study. Familial clustering was estimated by the recurrence risk ratio in siblings (¿s ) and offspring (¿o ) using intermediate and high prevalence values for MD in European population. A total of 431 patients (34%) reported a familial history of hearing loss or recurrent vertigo and 133 patients had a relative with possible MD. After clinical reevaluation, 93 relatives in 76 families were diagnosed of definite MD (8.4%), including three pairs of monozygotic twins. ¿s and ¿o were 16-48 and 4-12, respectively. We observed genetic heterogeneity, but most families had an autosomal dominant inheritance with anticipation. No clinical differences were found between sporadic and familial MD, except for an early onset in familial cases. We may conclude that MD has a strong familial aggregation and that sporadic and familial MDs are clinically identical.

The purpose of this study is to determine if surgical approach to the inner ear is feasible without generating a hearing loss in an animal model. Five Macaca fascicularis were used as experimental animals and followed up for 27 months. Mastoidectomy, posterior tympanotomy and promontorial cochleostomy were performed on four specimens and one specimen was kept as control animal. Before and after drilling and exposing the endosteal layer and the membranous labyrinth, otoacustic emissions (dPOAE) and auditory brainstem responses (ABR) were used to test hearing. In vivo experimental studies prove it is reliable to expose the membranous labyrinth without causing hearing loss. dPOAE were present after 3, 6, 12, 24 and 26 months of follow-up. Regarding the ABR results from the four M. fascicularis in which a cochleostomy has been carried out, auditory thresholds are within the 20-30 dB interval at 27 months of follow-up. Experimental studies support clinical experiences indicating it is feasible to surgically approach the membranous labyrinth of the cochlea without damaging its hearing function.

Abstract Conclusions: The degree of caloric weakness before surgery influences faster or slower recovery of patients undergoing vestibular schwannoma surgery. The Dizziness Handicap Inventory (DHI) is a good index to show the recovery of patients as it relates directly to an improvement or not of the subjective visual vertical (SVV). Objective: To evaluate the process of recovery of patients as measured by the SVV and the DHI after surgical removal of vestibular schwannoma. Methods: We studied 24 consecutive patients of the University Hospital of Salamanca who underwent vestibular schwannoma surgery. We assessed age, tumour size, degree of canalicular weakness and preoperative SVV, and their relationship with DHI and SVV at discharge and also at 1, 3 and 6 months postoperatively. Results: Patients with lesser degrees of caloric weakness took longer to normalize SVV than those with a higher caloric weakness before surgery (p &lt; 0.05). There was a significant correlation between DHI and improvements in SVV with time. The differences disappeared in 6 months where all patients, with greater or lesser degree of caloric weakness, had the same results.

The current classification, with the criteria it includes, allows labelling with an acceptable consensus to only 62% of the patients. Therefore, a modification in the classification is proposed in relation with the probable BPPV epigraph, as well a revision of the entries for vertigo-migraine and vertigo associated with migraine

Introduction: The assessment of the vestibulo-ocular reflex (VOR) is one of the main steps in clinically evaluating patients with dizziness. It can be performed at the bedside with common head-impulse test in which eye position is analysed at the end of the head-thrust. It is an important test due to its high specificity but low sensitivity. Material and Methods: We studied 179 patients with different types of balance- affecting disorders. The results were analysed in contingency tables. The clinical test was classified as normal or abnormal according to the absence or existence, respectively, of fixation saccades once the head-thrust was ended. The video head-impulse test (vHIT) was classified according to vestibulo-ocular reflex (VOR) gain and presence of fixation saccades. The speed of the slow phase of spontaneous nystagmus was also quantified, as well as the caloric test results. Results: There were significant differences (Chi-square test, P=0.00) for the findings in the clinical evaluation and with the vHIT: 32.1% of the tests performed yielded different findings in both tests. In the vHIT, the differences were due to the finding of normal gain with saccades; in these patients, the mean canal paresis was significantly abnormal: 39% ± 10%. Conclusions: The distribution of findings for the VOR bedside examination and for that with the help of a video system are significantly different; as such, the video head-impulse examination is not simply an added VOR detection and registration system. The difference relies mainly on a vHIT response characterised as of normal gain but with fixation saccades. These have been considered as the cause for the low sensitivity of the bedside VOR examination and sometimes regarded as normal responses; we have demonstrated that these findings are abnormal according to the findings of higher canal paresis in the caloric test.

Introduction: The assessment of the vestibulo-ocular reflex (VOR) is one of the main steps in clinically evaluating patients with dizziness. It can be performed at the bedside with common head-impulse test in which eye position is analysed at the end of the head-thrust. It is an important test due to its high specificity but low sensitivity. Material and methods: We studied 179 patients with different types of balance- affecting disorders. The results were analysed in contingency tables. The clinical test was classified as normal or abnormal according to the absence or existence, respectively, of fixation saccades once the head-thrust was ended. The video head-impulse test (vHIT) was classified according to vestibulo-ocular reflex (VOR) gain and presence of fixation saccades. The speed of the slow phase of spontaneous nystagmus was also quantified, as well as the caloric test results. Results: There were significant differences (Chi-square test, P=0.00) for the findings in the clinical evaluation and with the vHIT: 32.1% of the tests performed yielded different findings in both tests. In the vHIT, the differences were due to the finding of normal gain with saccades; in these patients, the mean canal paresis was significantly abnormal: 39% ± 10%. Conclusions: The distribution of findings for the VOR bedside examination and for that with the help of a video system are significantly different; as such, the video head-impulse examination is not simply an added VOR detection and registration system. The difference relies mainly on a vHIT response characterised as of normal gain but with fixation saccades. These have been considered as the cause for the low sensitivity of the bedside VOR examination and sometimes regarded as normal responses; we have demonstrated that these findings are abnormal according to the findings of higher canal paresis in the caloric test.

El temblor ortostático (TO) es una enfermedad neurológica de origen desconocido caracterizada por un temblor de 10-20Hz en las piernas en bipedestación. Se manifiesta por mareo e inestabilidad, que típicamente mejoran al apoyarse o sentarse y la ingesta de pequeñas cantidades de alcohol lo reduce de manera significativa. Se muestran 4 casos clínicos atendidos en nuestra consulta cuyo diagnóstico sugiere ser el de TO. Consideramos que ante un paciente con inestabilidad, es preciso plantearse como diagnóstico diferencial un TO. La historia clínica nos orienta hacia esta entidad y en caso de sospecha, el diagnóstico definitivo viene dado por el registro de la electromiografía en las extremidades inferiores en condición de reposo sentado y en ortostatismo donde se registra un temblor de 10-20Hz. El tratamiento es médico y, se emplea el clonazepam como primera opción terapéutica.

We have identified four distinct profiles of patients with definite Menière's disease that we consider as "mildly active elderly," "mildly active young," "active compensated," and "active uncompensated." We have demonstrated that only in a restricted popu

The treatment of patients with idiopathic sudden sensorineural hearing loss must be performed as an emergency measure in order to prevent long term hearing deficit. Steroids in monotherapy provide the best outcome. There is some controversy regarding the most efficient route but in order to prevent side effects, intratympanic treatment is the preferred choice, especially in diabetic patients. We here present the case of a patient that developed hyperglycemia after systemic and intratympanic dexamethasone treatment for sudden hearing loss. We conclude that after intratympanic treatment great caution must be taken.

Objective: To evaluate the value of different variables of the clinical history, auditory and vestibular tests and handicap measurements to define intractable or disabling Meniere's disease. Methods: This is a prospective study with 212 patients of which 155 were treated with intratympanic gentamicin and considered to be suffering a medically intractable Meniere's disease. Age and sex adjustments were performed with the 11 variables selected. Discriminant analysis was performed either using the aforementioned variables or following the stepwise method. Results: Different variables needed to be sex and/or age adjusted and both data were included in the discriminant function. Two different mathematical formulas were obtained and four models were analyzed. With the model selected, diagnostic accuracy is 77.7%, sensitivity is 94.9% and specificity is 52.8%. Conclusion: After discriminant analysis we found that the most informative variables were the number of vertigo spells, the speech discrimination score, the time constant of the VOR and a measure of handicap, the "dizziness index". (C) 2009 Elsevier Ireland Ltd. All rights reserved.

Introduction: The Sensory Organization Test of dynamic posturography allows a reliable assessment of the ability of any given patient to maintain a correct stability when conditions in the visual surrounding and/or support surface are deliberately modified. The results of this test can be analyzed according to the norms of the manufacturer of the device or through the application of specific formulae such as those by Cevette. Objectives: To evaluate if the Cevette formulae distinguish correctly between the normal and vestibular patterns, as well as observing the differences between these two groups of patients (normal and vestibular), obtained either through standardized calculation or by the Cevette formulae. The work has been restricted to patients diagnosed with unilateral Menière's disease who presented an active form of the disease and who had not suffered a recent crisis. Material and Methods: 63 patients were studied who fulfilled the inclusion criteria for this study. A clinical and instrumental audio-vestibular study was carried out. The results of the sensory organization test were analyzed according to the pattern offered by the device and through the application of the Cevette formulae. Results: In 63 patients the pattern obtained was normal or vestibular. In 41 the pattern obtained through one system of analysis or the other coincided but in 22 they did not. The analysis of patients using the Cevette formulae offers a higher capacity for clinical discrimination but is not sensitive to the bias introduced by age; however, combined with the classification offered by the device, it manages to differentiate two populations (normal and vestibular) with a very good audio-vestibular correlation. Conclusion: The combined assessment of the results of the sensory organization test using both the equipment analysis and the Cevette formulae provides much better and real information of clinical differences amongst patients with Menière's disease when the result is normal or of vestibular deficiency.

Objective: The objective of this study was to identify patients with otosclerosis and to characterize its clinical presentation among patients examined at our hospital with vertigo as the primary and most distressing symptom. Study Design: Retrospective chart review. Setting: Tertiary medical center. Patients: This study involved 40 patients suffering from dizziness and diagnosed with otosclerosis. Methods: At inclusion, the clinical status, as well as auditory (pure tone hearing level and speech audiometry, impedancemetry) and vestibular function (bedside, nystagmography, caloric test and rotator chair testing) were assessed. The results were analyzed using parametric and non-parametric tests, and the chi2 test. Results: The clinical presentation was diverse: 12 patients with Menière's syndrome (30%); 11 patients with spontaneous recurrent vertigo without hearing fluctuation (27.5%); 13 patients with positional vertigo (32.5%); 3 patients with chronic unrelapsing imbalance (7.5%); and 1 patient with acute unilateral vestibulopathy (2.5%). There was a lag between the detection of hearing loss and the beginning of vertigo attacks or imbalance in all patients. When measured through bone conduction, hearing loss was significantly different in patients with Menière's disease, spontaneous recurrent vertigo and positional vertigo. Conclusions: Dizziness, although frequent in patients with otosclerosis is rarely a cause for specific clinical assessment. There is a lag between the patient's perception of hearing loss and the initiation of vestibular symptoms, and it is not associated with any specific clinical disorder Otosclerosis can be found as any one of the most common vestibular disorders and in general, vestibular function tests reveal a more severe vestibular dysfunction than in the idiopathic forms. Level Of Evidence: 2A.