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Cervical and Ocular VEMPs in the Clinical Practice

Erica Zaia, MSc, RAUD

cVEMPs• described by Colebatch and colleagues in 1994

• myogenic potentials recorded from neck muscles in response to high level acoustic stimulation of the saccule

• not related to hearing thresholds

• saccular function: up-down and forward-backward

cVEMPs• ipsilateral inhibitory response:

• saccule

• inferior vestibular nerve

• vestibular nuclei

• medial vestibulospinal tract

• spinal accessory nerve (CN XI)

• sternocleidomastoid muscle

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cVEMPselectrode montage

cVEMPs

• Rosengren, S., Colebatch, J., Borire, A., Straumann, D., & Weber, K. (2016). cVEMP morphology changes with recording electrode position, but single motor unit activity remains constant. Journal of Applied Physiology, 120(8), 833-842.

cVEMPs

• Rosengren, S., Colebatch, J., Borire, A., Straumann, D., & Weber, K. (2016). cVEMP morphology changes with recording electrode position, but single motor unit activity remains constant. Journal of Applied Physiology, 120(8), 833-842.

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cVEMPs

• muscle contraction corrected amplitude - monitoring contraction

• Rosengren, S. (2015). Effects of muscle contraction on cervical vestibular evoked myogenic potentials in normal subjects. Clinical Neurophysiology, 126(11), 2198-2206.

cVEMPs• stimulus: ACS - air conduction tone burst

500 Hz = larger amplitude

• frequency tuning changes in Meniere’s and with age - try 1000 Hz

• age affects amplitude/presence of response

• 25% absent - 60-70 age group

• 40% absent - >70 age group

• bone conduction vibration can be used -saccule?• Singh, N. K., Kashyap, R. S., Supreetha, L., & Sahana, V. (2014). Characterization of age-related changes in sacculocolic

response parameters assessed by cervical vestibular evoked myogenic potentials. European Archives of Oto-Rhino-Laryngology, 271(7), 1869-1877.

cVEMPs• ACS - stimulus and recording parameters

stim rate 5/sec

gain 5000

low pass filter 5 - 30 Hz

high pass filter 1000 - 3000 Hz

analysis window 100ms

sweeps ~100 (replicate)

Papathanasiou, E. S., Murofushi, T., Akin, F. W., & Colebatch, J. G. (2014). International guidelines for the clinical application of cervical vestibular evoked myogenic potentials: An expert consensus report. Clinical Neurophysiology : Official Journal of the International Federation of Clinical Neurophysiology, 125(4), 658.

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cVEMPsINTERPRETATION OF RESULTS

• presence of p13 – n23

• amplitude symmetry at 120 - 135 dB pSPL(83 - 98 dB nHL)

larger amplitude - smaller amplitude x100larger amplitude + smaller amplitude

• AR 35 - 50% • absolute amplitude and 3rd window syndrome

cVEMPsINTERPRETATION OF RESULTS

• latency and latency difference: prolonged latencies may suggest brainstem abnormalities

• threshold: presence of p13-n23 with low level sound is sensitive and specific to diagnose inner bone dehiscence/3rd window syndrome

• clinical protocol: screening at 107 dB pSPL (70 dB nHL)

• find threshold if response is present

cVEMPsINTERPRETATION OF RESULTS

• conductive hearing loss and cVEMP

• even 20 dB air-bone gap can reduce or abolish cVEMPs (otosclerosis, middle ear disease)

• if cVEMPs are present, consider superior canal dehiscence/third window syndromes

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cVEMPsCLINICAL APPLICATIONS

• Superior Canal Dehiscence and other third window syndromes: sound/pressure evoked vertigo, disequilibrium, oscillopsia, autophony

• (pseudo-) conductive hearing loss (acoustic reflexes are present)

• cVEMP amplitude with loud sound is higher (but may still overlap with young normal subjects)

• subthreshold response - cVEMP is present at lower stimulus levels (< 85 dB nHL) 86% sensitivity and 90% specificity

Zuniga, M. G., Janky, K. L., Nguyen, K. D., Welgampola, M. S., & Carey, J. P. (2013;2012;). Ocular versus cervical VEMPs in the diagnosis of superior semicircular canal dehiscence syndrome. Otology & Neurotology : Official Publication of the American Otological Society, American Neurotology Society [and] European Academy of Otology and Neurotology, 34(1), 121.

cVEMPsSUPERIOR CANAL DEHISCENCE

cVEMPsCLINICAL APPLICATIONS

• Meniere’s Disease: cVEMPs may help in differential diagnosis against other chronic recurrent disorders (i.e. Vestibular Migraine)

• ACS cVEMP in Meniere’s Disease may:

• tune to 1000Hz (lower amplitude/poor morphology/ absent at 500 Hz)

• be augmented in the initial/acute stages and with glycerol and furosemide

• fluctuate during acute attacks

Murofushi, T., Komiyama, S., & Suizu, R. (2016). Detection of saccular endolymphatic hydrops in Ménièreʼs disease using a modified glycerol cVEMP test in combination with the tuning property test. Otology & Neurotology, 37(8), 1131-1136.

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cVEMPsMENIERE’S DISEASE

cVEMPsCLINICAL APPLICATIONS

• Vestibular Neuritis (VN): cVEMP is absent if Inferior Vestibular Nerve is affected

• “typical” VN thought to affect superior branch

• 56% superior

• 42% both

• 2% inferior

• value of vHIT

Taylor, R. L., McGarvie, L. A., Reid, N., Young, A. S., Halmagyi, G. M., & Welgampola, M. S. (2016). Vestibular neuritis affects both superior and inferior vestibular nerves.Neurology,87(16), 1704-1712.

cVEMPsCLINICAL APPLICATIONS

• Benign Paroxysmal Positional Vertigo (BPPV): no consensus

• ACS cVEMPs absent in 30% of patients; no difference between recurrent and non-recurrent groups

• Xu, H., Tong, M. C. F., Chen, L., Zhang, Q., Liang, F., Thong, J. F., . . . Song, X. (2016). Evaluation of the utricular and saccular function using oVEMPs and cVEMPs in BPPV patients. Journal of Otolaryngology - Head & Neck Surgery, 45(12)

• ACS cVEMPs not significantly different from controls and unaffected ears

• Singh, N. K., Sinha, S. K., Govindaswamy, R., & Kumari, A. (2014). Are cervical vestibular evoked myogenic potentials sensitive to changes in the vestibular system associated with benign paroxysmal positional vertigo? Hearing, Balance and Communication, 12(1), 20-26. doi:10.3109/21695717.2014.883208

• useful to identify underlying causes of BPPV

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cVEMPsTAKE HOME MESSAGE

• isolated “unexplained” cVEMP abnormality (absence/asymmetry)

• verify electrode placement and muscle contraction

• change to 1000 Hz tone

• investigate true conductive hearing loss/middle ear disease

• correlate with oVEMP, vHIT and calorics findings

oVEMPs

• described in 2007 as a potential test for vestibular function

• extraocular myogenic activity associated with vestibulo-ocular reflex (VOR)

• oVEMP recording of short latency potentials on the inferior oblique muscle

• Rosengren, S. M., Welgampola, M. S., & Colebatch, J. G. (2010). Vestibular evoked myogenic potentials: Past, present and future. Clinical Neurophysiology, 121(5), 636-651.

oVEMPs

• contralateral excitatory response:

• utricle (and?) - stim dependent?

• superior vestibular nerve

• vestibular nuclei

• medial longitudinal fasciculus

• oculomotor nerve (CN III)

• inferior oblique muscle

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oVEMPs

• first described (classic or standard) montage

• inferior oblique relaxed = upwards gaze

oVEMPs

•Govender, S., Cheng, P., Dennis, D., & Colebatch, J. (2016). Electrode montage and gaze effects on ocular vestibular evoked myogenic potentials (oVEMPs).Clinical Neurophysiology,127(8), 2846-2854.

•Sandhu, J., George, S., & Rea, P. (2013). The effect of electrode positioning on the ocular vestibular evoked myogenic potential to air-conducted sound. Clinical Neurophysiology,124(6), 1232-1236.

oVEMPs• stimulus: ACS - air conduction tone burst 500 Hz

• conductive hearing loss

• greater age effect (smaller response)

• role in SCD ***

• BCV - bone conduction vibration on Fz

• bypasses middle ear

• larger and more reliable responses

• less false-positives

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oVEMPs• BCV - bone conduction vibration

Reflex Hammer w/ trigger Mini-shaker

oVEMPsINTERPRETATION OF RESULTS

• presence/absence of responses

• Asymmetry Ratio (AR) 35 - 50%

larger amplitude - smaller amplitude x100larger amplitude + smaller amplitude

• elongated latencies - nerve conduction (MS)

oVEMPsCLINICAL APPLICATIONS

• Superior Canal Dehiscence (SCD) and other third window syndromes

• abnormally high amplitude

• peak to peak amplitude > 17.1 μV for ACS - 500 HzZuniga, M. G., Janky, K. L., Nguyen, K. D., Welgampola, M. S., & Carey, J. P. (2013;2012;). Ocular versus cervical VEMPs in the diagnosis of superior

semicircular canal dehiscence syndrome. Otology & Neurotology : Official Publication of the American Otological Society, American Neurotology Society [and] European Academy of Otology and Neurotology, 34(1), 121.

• also observed with BCV at Fz; related to size of dehiscence at high res CT; base to peak > 10 μV; present with BCV at Cz

Manzari, L., Burgess, A. M., McGarvie, L. A., & Curthoys, I. S. (2012). Ocular and cervical vestibular evoked myogenic potentials to 500 hz fz bone-conducted vibration in superior semicircular canal dehiscence. Ear and Hearing, 33(4), 508-520.

• marked asymmetry in unilateral cases

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oVEMPsSUPERIOR CANAL DEHISCENCE

oVEMPsCLINICAL APPLICATIONS

Manzari, L., Burgess, A. M., McGarvie, L. A., & Curthoys, I. S. (2013). An indicator of probable semicircular canal dehiscence: Ocular vestibular evoked myogenic

potentials to high frequencies. Otolaryngology–Head and Neck Surgery, 149(1), 142-145.

healthy SCD

• frequency tuning changes

oVEMPsCLINICAL APPLICATIONS

• Benign Paroxysmal Positional Vertigo (BPPV)

• ACS oVEMPs absent in 56.7% of patients; recurrent group significantly higher rate of absent responses Xu, H., Tong, M. C. F., Chen, L., Zhang, Q., Liang, F., Thong, J. F., . . . Song, X. (2016). Evaluation of the utricular and saccular function using oVEMPs and cVEMPs in BPPV patients. Journal of Otolaryngology - Head & Neck Surgery, 45(12)

• BCV oVEMP amplitude increased 1 week after successful particle repositioning Bremova, T., Bayer, O., Agrawal, Y., Kremmyda, O., Brandt, T., Teufel, J., & Strupp, M. (2013). Ocular VEMPs indicate repositioning of otoconia to the utricle after successful liberatory maneuvers in benign paroxysmal positioning vertigo. Acta Oto-Laryngologica, 133(12), 1297-1303.

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oVEMPsBPPV

oVEMPsCLINICAL APPLICATIONS

• Vestibular Neuritis (VN): oVEMP is absent if Superior Vestibular Nerve is affected

• 56% superior

• 42% both

• 2% inferior

oVEMPsCLINICAL APPLICATIONS

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oVEMPsTAKE HOME MESSAGE

• select electrode montage and ensure upgaze

• have ACS (500 Hz and 4000 Hz) and BCV available

• select stimulus according to diagnostic hypotheses

cVEMPs• described by Colebatch and colleagues in 1994

• myogenic potentials recorded from neck muscles in response to high level acoustic stimulation of the saccule

• not related to hearing thresholds

• saccular function: up-down and forward-backward

cVEMPselectrode montage

cVEMPs

• Rosengren, S., Colebatch, J., Borire, A., Straumann, D., & Weber, K. (2016). cVEMP morphology changes with recording electrode position, but single motor unit activity remains constant. Journal of Applied Physiology, 120(8), 833-842.

cVEMPs

• muscle contraction corrected amplitude - monitoring contraction

• Rosengren, S. (2015). Effects of muscle contraction on cervical vestibular evoked myogenic potentials in normal subjects. Clinical Neurophysiology, 126(11), 2198-2206.

cVEMPs• stimulus: ACS - air conduction tone burst

500 Hz = larger amplitude

• frequency tuning changes in Meniere’s and with age - try 1000 Hz

• age affects amplitude/presence of response

• 25% absent - 60-70 age group

• 40% absent - >70 age group

• bone conduction vibration can be used -saccule?• Singh, N. K., Kashyap, R. S., Supreetha, L., & Sahana, V. (2014). Characterization of age-related changes in sacculocolic

response parameters assessed by cervical vestibular evoked myogenic potentials. European Archives of Oto-Rhino-Laryngology, 271(7), 1869-1877.

cVEMPsSUPERIOR CANAL DEHISCENCE

cVEMPsMENIERE’S DISEASE

cVEMPsCLINICAL APPLICATIONS

• Vestibular Neuritis (VN): cVEMP is absent if Inferior Vestibular Nerve is affected

• “typical” VN thought to affect superior branch

• 56% superior

• 42% both

• 2% inferior

• value of vHIT

Taylor, R. L., McGarvie, L. A., Reid, N., Young, A. S., Halmagyi, G. M., & Welgampola, M. S. (2016). Vestibular neuritis affects both superior and inferior vestibular nerves.Neurology,87(16), 1704-1712.

oVEMPs

•Govender, S., Cheng, P., Dennis, D., & Colebatch, J. (2016). Electrode montage and gaze effects on ocular vestibular evoked myogenic potentials (oVEMPs).Clinical Neurophysiology,127(8), 2846-2854.

•Sandhu, J., George, S., & Rea, P. (2013). The effect of electrode positioning on the ocular vestibular evoked myogenic potential to air-conducted sound. Clinical Neurophysiology,124(6), 1232-1236.

oVEMPsSUPERIOR CANAL DEHISCENCE

oVEMPsCLINICAL APPLICATIONS

Manzari, L., Burgess, A. M., McGarvie, L. A., & Curthoys, I. S. (2013). An indicator of probable semicircular canal dehiscence: Ocular vestibular evoked myogenic

potentials to high frequencies. Otolaryngology–Head and Neck Surgery, 149(1), 142-145.

healthy SCD

• frequency tuning changes

oVEMPsBPPV

oVEMPsCLINICAL APPLICATIONS

• Vestibular Neuritis (VN): oVEMP is absent if Superior Vestibular Nerve is affected

• 56% superior

• 42% both

• 2% inferior

oVEMPsCLINICAL APPLICATIONS