cervical and ocular vemps in the clinical practice...2/15/17 6 cvemps meniere’s disease cvemps...
TRANSCRIPT
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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