Re-evaluation of normative electronystagmography data in healthy ageing

Previous work by our group questions the validity of existing electronystagmography (ENG) reference ranges in the elderly. We aim to establish valid reference ranges for ENG in people over 65 on the Nicolet Nystar Plus system. Ninety-six healthy asymptomatic subjects over 65 underwent ENG, including spontaneous and positional nystagmus, saccades, smooth pursuit, optokinetic nystagmus and bithermal calorics; 95% reference ranges with confidence intervals were calculated. The newly determined reference ranges were far wider than those provided by the ENG equipment manufacturer for eight out of 11 parameters (all P < 0.001). Vestibular function is known to deteriorate and become more variable with age. The failure to reflect this change in currently used reference ranges may have contributed to the high rates of vestibular disease reported in some series of dizzy elderly patients. Clinical interpretation of ENG depends on valid reference ranges.     

Is electronystagmography of diagnostic value in the elderly?

Is electronystagmography of diagnostic value in the elderly? We aimed to determine the diagnostic value of electronystagmography (ENG) in a community‐based sample of dizzy subjects over 65 years old. A total of 96 asymptomatic controls and 149 dizzy subjects underwent ENG. Clinical diagnoses were made on standardized criteria. ENG results were classed as normal or abnormal, according to reference ranges derived from the controls. Rates of ENG abnormality in different diagnostic categories, sensitivities, specificities and predictive values were calculated. Central vascular disease was common (105 out of 149 subjects); peripheral vestibular disease was not (14). Spontaneous nystagmus had a positive predictive value of 95% for central vascular disease, but was only 18%‐sensitive, and was usually detectable clinically. ENG had no other significant diagnostic value. ENG failed to discriminate dizzy subjects from controls and failed to differentiate various dizziness syndromes. ENG was of no practical value in this community‐derived sample of dizzy elderly subjects.     

Is electronystagmography of diagnostic value in the elderly?

We aimed to determine the diagnostic value of electronystagmography (ENG) in a community-based sample of dizzy subjects over 65 years old. A total of 96 asymptomatic controls and 149 dizzy subjects underwent ENG. Clinical diagnoses were made on standardized criteria. ENG results were classed as normal or abnormal, according to reference ranges derived from the controls. Rates of ENG abnormality in different diagnostic categories, sensitivities, specificities and predictive values were calculated. Central vascular disease was common (105 out of 149 subjects); peripheral vestibular disease was not (14). Spontaneous nystagmus had a positive predictive value of 95% for central vascular disease, but was only 18%-sensitive, and was usually detectable clinically. ENG had no other significant diagnostic value. ENG failed to discriminate dizzy subjects from controls and failed to differentiate various dizziness syndromes. ENG was of no practical value in this community-derived sample of dizzy elderly subjects.     

Abnormalities of post-caloric nystagmus induced by postural change

Post-caloric nystagmus, the reverse secondary phase of caloric nystagmus after the cessation of primary-phase nystagmus, can easily be elicited by postural change. It has been related to the mechanism of vestibular adaptation, and exaggerated responses have been shown in some neurological disorders. Post-caloric nystagmus induced by postural change was analyzed in normal young adults (16 ears), elderly people (age > or = 65 years, 18 ears), patients with central lesions (40 ears) and patients with peripheral vestibulopathy (25 ears). The duration, maximum frequency and maximum slow-phase velocity of the primary phase of caloric nystagmus and of post-caloric nystagmus were documented. The duration, frequency and velocity ratios of post-caloric to primary-phase nystagmus were calculated. The results showed that post-caloric nystagmus induced by postural change was observed in 14 ears (88%) of normal young adults, 10 ears (56%) of elderly patients, 31 ears (78%) of patients with central lesions and 22 ears (88%) of patients with peripheral lesions. The duration and slow-phase velocity ratios for the central lesion group were found to be relatively higher than those for the control group (p < 0.05). A significant positive correlation between the intensities of post-caloric and primary-phase nystagmus was found in all groups except in the central lesion group. Abnormalities of post-caloric nystagmus induced by postural change may occur in the form of exaggerated response or failure of elicitation, which were observed with various central neuro-otological lesions and as a result of the aging process.     

Observation of Vestibular Asymmetry in a Majority of Patients over 50 Years With Fall-Related Wrist Fractures

Previously, we have observed vestibular asymmetry in about one-third of healthy senior citizens and in about two-thirds of subjects with previous hip fractures and no other significant ailments. Wrist fractures are considered a harbinger of hip fractures. If vestibular asymmetry is correlated with falls and fractures among the elderly then it should also be reflected among subjects with wrist fractures. Sixty-six consecutive patients (mean age 67.8 years) who had sustained a fall-related wrist fracture during a 10-month period were included in the study. The frequency of head shake nystagmus among the patients was compared to that found among 49 healthy senior citizens (mean age 74.9 years). Nystagmus after head shaking, indicating asymmetric vestibular function, was found in 50 participants (76%) (p &lt;0.001). Thirty-eight of these were graded with distinct or prominent nystagmus responses. Sixty percent of the subjects with horizontal nystagmus had a wrist fracture coinciding with the slow phase of nystagmus. Twenty-three subjects reported 30 previous fall-related fractures during the previous 10 years. Subjects with nystagmus after head shaking sustained 26 of these fractures. The frequency of signs of vestibular asymmetry was significantly higher (p &lt;0.001) among the subjects than among healthy senior citizens. These findings suggest that an asymmetric vestibular function could be an epidemiologically important contributory factor to falls and wrist fractures among the elderly population.     

Aging and reference values of the parameters in optokinetic nystagmus

Changes in optokinetic nystagmus by age were assessed, and preparation of reference values by age was made by the use of the data from 834 reference subjects. As a result, changes by age were observed at the test on optokinetic nystagmus. The reference values by these changes can be approximated with the quadratic and was considered, therefore, to be useful clinically. Four parameters were set for the test items for optokinetic nystagmus as the total number of nystagmus (NYS); the mean of eye velocity during the fast phase of nystagmus (FM); the algebraic summations of eye velocity (VEL) and amplitude (AMP) during the slow phase of nystagmus. As the process for statistical analysis, variables were divided into 7 groups, and after removing outlier (any extraneous data) in each group, changes in variables by age were assessed by the one-way analysis of variance and the method of multiple comparison (Ryan's method). As a result: 1) the age group of each variable seemed to develop into normal distribution; 2) it was presumed that change in NYS by age is less; 3-1) regarding FM, VEL and AMP, no change was observed in the variable by ages on 30s and 40s; and 3-2) however, decrease in the measured value was observed in ages on 60s along with aging. From these, the ages on 50s are the generation when the measured values of optokinetic nystagmus change. On the other hand, the reference values calculated, taking age into consideration, could be approximated with the quadratic.(ABSTRACT TRUNCATED AT 250 WORDS)     

Residual dizziness after successful repositioning maneuvers for idiopathic benign paroxysmal positional vertigo in the elderly

Even after successful repositioning maneuvers for benign paroxysmal positional vertigo (BPPV), some patients report dizziness lasting for a certain period afterwards. We studied the prevalence and clinical factors associated with residual dizziness in a sample of elderly patients. Sixty outpatients over 65 years of age, affected by idiopathic BPPV were recruited; the exclusion criterion was a history of previous episodes of vertigo, including positional. The patients were asked to describe their self-perceived anxiety for vertigo on a Visual Analogue Scale (VAS) and successively treated with appropriate maneuvers till resolution of nystagmus. Data concerning the demographic and clinical features of BPPV were collected. Patients were followed until complete resolution of subjective dizziness and imbalance without positional nystagmus. Data about residual dizziness were collected from the second day from resolution of BPPV. Clinical and demographic factors related to residual dizziness were analyzed. Twenty-two subjects (37%) reported residual dizziness. In these subjects, the mean duration of residual dizziness was 13.4 ± 7.5 days. No association was observed between residual dizziness and gender, involved canal and the number of repositioning maneuvers before resolution. On the other hand, age older than 72 years, symptom duration greater than 9 days and VAS scale for anxiety greater than 10/100 were associated with an increased risk of residual dizziness. The odds ratio were respectively 6.5 (age—residual dizziness, Confidence Interval 95%), 6.5 (duration of vertigo—residual dizziness, Confidence Interval 95%) and 15.5 (anxiety levels—residual dizziness, Confidence Interval 95%). Longer symptom duration before diagnosis was associated with higher anxiety levels. The results underline the necessity for an early and correct diagnosis of BPPV, especially in the elderly.     

Quantitative vestibular function testing in elderly patients with dizziness

Electronystagmography was used to examine 103 elderly patients complaining of dizziness. This series of tests included tests for pathologic nystagmus, saccades, smooth pursuit, and optokinetic nystagmus, as well as bithermal caloric testing and rotational testing. One or more specific diagnoses were identified in 100 patients (86.2%), with the two most common diagnoses being benign positional vertigo (30 patients, or 25.9%) and cerebrovascular disorders (25 patients, or 21.6%). An abnormality was found on ENG in 75 (65%) of the patients tested, the most common of these being a unilateral hypoexcitability to caloric stimulation. In most cases, the ENG data was used to support a presumptive diagnosis that was based on the patient's history and examination, although in 4 cases ENG provided the critical diagnostic information by identifying decreased caloric and rotational responses in patients with nonspecific dizziness and dysequilibrium.     

Multiple positional nystagmus suggests multiple canal involvement in benign paroxysmal positional vertigo

Conclusion. Video-oculography demonstrates a higher occurrence of atypical positional nystagmus in patients with benign paroxysmal positional vertigo (BPPV). This includes anterior and horizontal canal variants and multiple positional nystagmus, suggesting combined lesions affecting several canals. Objective. To analyse the video-oculographic findings of positional tests in patients with BPPV. Material and methods. Seventy individuals with symptoms of BPPV and positional nystagmus were included in this study. The diagnosis was based on a history of brief episodes of vertigo and the presence of positional nystagmus as confirmed by video-oculographic examination during the Dix–Hallpike test, the McClure test or the head-hanging manoeuvre. Patients were treated by means of different particle repositioning manoeuvres according to the affected canal (Epley's manoeuvre for the posterior or anterior canals and Lempert's manoeuvre for the lateral canal) and the effectiveness was evaluated at 7 and 30 days. Results. Twenty-nine individuals (41.43%) presented an affected unilateral posterior canal. Fifteen patients (21.43%) presented a pure horizontal direction-changing positional nystagmus consistent with a diagnosis of horizontal canal BPPV. Twelve individuals (17.14%) presented a unilateral down-beating nystagmus, suggesting possible anterior canal BPPV. In addition, 14 patients (20%) showed multiple positional nystagmus during the examination corresponding to simultaneous multi-canal BPPV, 5 had bilateral posterior canal BPPV and 2 presented a positional down-beating nystagmus in both left and right Dix–Hallpike manoeuvres and the head-hanging manoeuvre, which is highly suggestive of anterior canal BPPV. However, seven individuals showed positional horizontal and vertical side-changing nystagmus that could not be explained by single-canal BPPV. These patients with multiple positional nystagmus showed changing patterns of positional nystagmus at follow-up.     

Management of Benign Paroxysmal Positional Vertigo in an Adult With Severe Osteogenesis Imperfecta

The purpose of this case report was to describe the evaluation and management of atypical benign paroxysmal positional vertigo (BPPV) in an adult with severe osteogenesis imperfecta. A 29-year-old male was referred to a physical therapist with extensive experience in vestibular rehabilitation who provided horizontal canal BPPV treatment with a canalith repositioning maneuver over two treatment sessions. The individual's symptoms had reduced by 65% and his nystagmus during the roll test was reduced. Extreme care is needed to safely reposition individuals living with severe osteogenesis imperfecta, but the repositioning can reduce symptoms and improve quality of life. Laryngoscope, 130:2241–2244, 2020     

The value of dynamic posturography (Equitest) in preparing an expert's report

BACKGROUND: Expert appraisals of vestibular disorders and their effects on daily life are essentially based on an evaluation of the patient's subjectively described symptoms. The aim of the present study was to ascertain the extent to which dynamic posturography is able to assist in the preparation of expert's reports. MATERIAL AND METHODS: 60 patients underwent a survey of their balance impairment. Both a nystagmus analysis, with its objective criteria, and dynamic posturography were carried out. The investigation into reduction of fitness for work (MdE) made reference to the criteria specified in the table by STOLL. The data obtained were subjected to both correlation and variance analysis. RESULTS: Although the results of this analysis revealed no direct statistical dependency, they indicated a tendency for the composite values to be correlated with the nystagmus scores and/or the MdE values (when the nystagmus score and/or the MdE increases, the composite value decreases). CONCLUSIONS: The Equitest is, according to the available data, not able to replace the currently valid MdE scores. Nevertheless, it represents a means of providing objective data about the vestibulo-spinal reflex. The test also reveals any tendencies towards simulation and aggravation. In the context of a specific nystagmus analysis, the Equitest offers an additional means of providing an objective background to back up the more subjective assessment of MdE.     

Subclassification of vestibular disorders by means of statistical analysis in caloric labyrinth testing

Objective In the past, various attempts were made to perform a quantitative analysis of nystagmographic findings but their diagnostic value was limited. Therefore, the authors present a multivariate analysis of nystagmus findings with the aim of increasing the precision of diagnostic differentiation in cases of vestibular dysfunction.

Material and Methods A group of 387 patients and 40 healthy volunteers were examined over a 14-month period using electronystagmography after stimulation by bithermal, bilateral irrigation of the labyrinth. Amplitude, slow-phase velocity, frequency and directional preponderance were evaluated.

Results No defined normal values for caloric nystagmus parameters could be obtained. However, by using the Mann–Whitney U-test and logistic regression analysis a differentiation between pathological and healthy findings as well as between central and peripheral vestibular disorders and even between distinct vestibular disease entities is possible. Using these methods, the nystagmus amplitude was found to be the strongest discriminating parameter. Therefore, sole assessment of nystagmographic findings by selective calculation of the nystagmus slow-phase velocity falls short of the potential offered by electronystagmographic registration.

Conclusion For daily clinical routine, counting nystagmus beats leads to the same diagnostic precision as the analysis of slow-phase velocities. In contrast, multivariate analysis of several nystagmus parameters can distinguish between distinct diseases with fairly high precision. This stepwise analysis of nystagmographic data could create the basis for an expert-system tool in the near future.     

Effects of ocular fixation on perrotatory nystagmus in damped pendular rotation test

Summary Effects of ocular fixation on pendular rotation nystagmus were investigated in 65 patients. There were 25 with peripheral vestibular or vestibulo-cochlear disorders, 17 with central vestibular disorders, five with congenital nystagmus, 16 patients over 60 years old with vertigo in whom peripheral vestibular disorders were ruled out, however, the causes were unknown.Damped pendular rotation test (DPRT) was performed both under darkness and employing mental arithmetic and under ocular fixation. These findings were related to those of caloric vestibular suppression test (VST) by Takemori and those of optokinetic pattern test (OKP), eye tracking test (ETT), and spontaneous nystagmus.Thirteen of 17 patients with central vestibular disorders and five with congenital nystagmus showed loss of visual suppression during ocular fixation in DPRT, whereas in cases of peripheral lesions, visual suppression was observed. Loss of visual suppression during ocular fixation in DPRT was often seen in cases of brainstem and cerebellar lesions. In brainstem lesions, perrotatory nystagmus was evoked during ocular fixation, whereas no nystagmus was seen in darkness with eyes open. In cerebellar lesions, perrotatory nystagmus was partly suppressed or decreased during ocular fixation. Relationships between the direction of the visual suppression during ocular fixation in DPRT and the side of the lesion were not apparent.Ocular fixation test in DPRT has a diagnostic value not only for central lesions, but for differentiating brainstem lesion from cerebellar lesion with the findings in DPRT under darkness. The findings under ocular fixation in DPRT are closely related to those of VST in cases of caloric nystagmus.     

42例轻嵴帽患者的眼震特点及临床疗效分析

目的 对轻嵴帽患者的眼震特点及临床疗效进行分析。方法 收集2018年1月—至2021年1月就诊于晋中市第一人民医院耳鼻咽喉科眩晕门诊并确诊为轻嵴帽患者42例为研究对象,通过视频眼震电图记录并分析其眼震数据,全部患者均给予Barbecue法复位治疗及复位后予口服药物治疗,评价即时、1周后及1个月后疗效。结果 42例患者中继发于突发性耳聋2例(4.8%),出现直立位自发性眼震10例(23.8%),仰卧位眼震24例(57.1%),眼震均朝向健侧,并出现眼震消失平面即第二零平面,且位于患侧。所有患者双侧转头位均出现持续性向地性位置性眼震,平均持续时间＞1 min,平均慢相角速度(SPV)＞20°/s,且无明显潜伏期,治疗后即时痊愈0例,改善5例(11.9%),无效37例(88.1%)。1周后痊愈2例(4.8%),改善18例(42.9%),无效22例(52.4%);1个月后痊愈39例(92.9%),改善3例(7.1%),无效0例。即时疗效、1周后疗效及1个月后疗效比较差异具有统计学意义(P＜0.05);年龄与即时疗效相关(P＜0.05);患侧眼震强度与1周后疗效相关(P＜0.05),患侧眼震强度及持续时间与1个月后疗效相关(P＜0.05)。结论 轻嵴帽眼震特点表现为持续性向地性位置性,持续时间长,且无潜伏期,部分可出现零平面,并伴随仰卧位眼震发生。该疾病具有一定自愈性,预后良好。年龄、患侧眼震强度、时长对患者的预后有影响,年龄小、眼震强度弱且眼震持续时间短的患者疗效相对较好。     

Sudden sensorineural hearing loss with positional vertigo: Initial findings of positional nystagmus and hearing outcomes

Objectives: To investigate the initial findings of positional nystagmus in patients with sudden sensorineural hearing loss (SSNHL) and positional vertigo, and to compare hearing improvement among patients with different types of positional nystagmus. Design: The characteristics of positional nystagmus upon initial examination were analysed, and the initial mean pure-tone audiometry (PTA) threshold was compared with that at three months after treatment. Study sample: Forty-four SSNHL patients with concomitant positional vertigo were included. Results: Positional nystagmus was classified into five subgroups; persistent geotropic direction-changing positional nystagmus (DCPN) in head-roll test (HRT) and negative Dix-Hallpike test (DHT), persistent apogeotropic DCPN in HRT and negative DHT, positive DHT and negative HRT, persistent geotropic DCPN in HRT and positive DHT, and persistent apogeotropic DCPN in HRT and positive DHT. PTA threshold improvement was significantly greater in SSNHL patients with negative DHT than with positive DHT (p?=?0.027). Conclusions: When geotropic DCPN was elicited by HRT, the nystagmus was persistent, which suggests that alteration of specific gravity of the endolymph, rather than the lateral canal canalolithiasis, may be a cause of this characteristic positional nystagmus. Positive DTH may be a prognostic factor for worse hearing recovery among patients with SSNHL and positional vertigo.     

Dynamics of canal response to head-shaking test in benign paroxysmal positional vertigo

Conclusions. Time constant and maximum slow phase velocity (SPV) of head-shaking nystagmus (HSN) demonstrated a differential canal response to head shaking in 24% of patients with posterior canal benign paroxysmal positional vertigo (BPPV). We suggest that vestibular lithiasis has a limited contribution to the mechanism that generates HSN. Objective. To determine the canal response to head shaking in BPPV. Patients and methods. This was a case-control study including 104 individuals with BPPV. The diagnosis was based on the presence of vertigo and nystagmus during the positional test. Subjects were examined by the horizontal and vertical head-shaking test. Eye movements were recorded on a video camera to analyze the nystagmus. The head was shaken passively in the horizontal and sagittal planes, respectively, for horizontal and vertical HSN at a frequency of 2 Hz. HSN was considered when six consecutive beats of nystagmus with an SPV of at least 2°/s were detected. Main outcome measures were the presence of horizontal and vertical HSN, maximum SPV of HSN, time constant of HSN, and canal paresis. Results. Maximum SPV of vertical HSN was higher in BPPV patients with posterior canal BPPV (n=10) than in controls (p=0.04). Moreover, the time constant of vertical HSN was significantly lower for posterior canal BPPV when compared with controls (p<0.02).     

A visual suppression test using post-rotatory nystagmus.

The visual suppression test is one method for examining the function of visual fixation and visual influence on vestibular nystagmus. In this study the visual suppression test using post-rotatory nystagmus was investigated in 65 normal subjects and 142 clinical cases with cerebellar lesions. In 65 normal subjects the mean +/- standard deviation of visual suppression of the slow phase velocity on post-rotatory nystagmus was 69 +/- 11%. As to the stimulation for visual suppression test, the post-rotatory method using rotatory stimulation is milder than caloric stimulation. This method is far simpler to analyze than the visual suppression test using pendular rotatory nystagmus and other vestibulo-ocular reflex tests. In the 142 patients with cerebellar lesions, reduced or abolished visual suppression on post-rotatory nystagmus was seen in 89 patients with radiologically confirmed disturbances in the vestibulo-cerebellum. And this method could identify the lesion side in the cerebellum. These results showed a correlation between the visual suppression test using post-rotatory nystagmus and one using caloric nystagmus in 65 normal subjects and 142 clinical cases with cerebellar lesions.     

Persistent geotropic nystagmus—a different kind of cupular pathology and its localizing signs

Abstract

Conclusion. A persistent geotropic positional nystagmus indicates a dysfunction in the lateral semicircular canal with a cupula of less specific weight than the surrounding endolymph. It is possible to determine the side of the affected cupula by recording the nystagmus pattern in yaw and pitch plane. Objectives. To identify the clinical features in patients with a persistent geotropic positional nystagmus, establish lateralizing signs and relate the findings to a pathophysiologic mechanism. Patients and methods. Six patients with acute onset vertigo of a peripheral origin and persistent geotropic nystagmus were examined with videonystagmoscopy and the nystagmus characteristics in different positions of the head in yaw and pitch plane were studied. Results. Besides the persistent geotropic nystagmus, a zero zone was found with no nystagmus, beyond which the nystagmus changed direction when the head of the patient in supine position was gradually rotated from side to side. The zero zone was present when the head was turned slightly towards one side and is thought to represent a position where the affected cupula is aligned with the gravitational vertical. With the head bent forwards the nystagmus direction was to the non-affected side and when the head was bent backwards to the affected side.     

Chronic vestibular and auditory effects of marijuana

The objective of this study was to ascertain vestibular dysfunction and impaired hearing resulting from the chronic use of marijuana. Electro-nystagmography was utilized to record gaze nystagmus, tracking a pendulum, spontaneous nystagmus, positional nystagmus, and rotation on the torsion swing. Pure tone thresholds were also obtained. The results of these tests, for normals and heavy marijuana users, were then compared. The comparison of these results showed significant changes in vestibular functions for chronic marijuana users in: a. decrease in maximum amplitude on torsion swing; b. increase in incidence of nystagmus in two or more supine positions; and c. decrease in speed of slow component on caloric tests.     

Cross-cultural adaptation of an Arabic version of the 10-item hearing handicap inventory

Objective: The purpose of this study was to translate and culturally adapt an Arabic version of the hearing handicap inventory for the elderly - screening (HHIE-S). Design: The HHIE-S was translated following cross-cultural adaptation guidelines, and pretested in 20 elderly patients with hearing impairment. Next, the adapted Arabic HHIE-S underwent psychometric evaluation. The results were confirmed by pure-tone audiometer (PTA) examination. The patients completed the HHIE-S again after one hour. The validation of the questionnaire using Cronbach's alpha (internal consistency), (construct validity), and intraclass correlation coefficients (repeatability) was performed. Study sample: Twenty elderly subjects with hearing impairment were recruited for the pretesting stage, and 100 elderly subjects were recruited for the psychometric evaluation stage. Patients with acute illness, functional dependency, cognitive impairment, and previous users of hearing aids were excluded. Results: The adapted Arabic HHIE-S showed good internal consistency (α = 0.902). Construct validity was good, as high correlations were found between the scale and the PTA outcome (r = 0.688, p = 0.000). Repeatability was high (ICC = 0.986). Conclusions: This study showed that the adapted Arabic HHIE-S is a valid and reliable questionnaire for the assessment of handicapping hearing impairment in Egyptian elderly patients.