the tullio phenomenon in patients with meniere's disease as revealed with posturography
TRANSCRIPT
Acta Otolaryngol (Stockh) 1991; Suppl. 481: 593-595
The Tullio Phenomenon in Patients with Meniere's Disease as Revealed with Posturography
HISAYOSHI ISHIZAKI,' ILMARI PYYKKO.' HEIKKI AALTO' and JUKKA STARCK' From the Depar tment of Otolaryngology . ' H ~ I ~ ~ I U I I I ( I ~ S I ~ lJniwr.sit.v Sc~lrool of Medic,inc,. H(rtii(iin(it.sri. Jtrptrn. 'Uniwrsity Hospi ta l of Helsinki. nnd 'Institrite of' Occrrptrrionrrl Hetrlth. Helsinki. Finltrnd
The effect of low frequency sound (LFS) on postural stability was studied in 55 healthy volunteers and in 50 patients with Meniel-e's disease. The sound levels ranged from 130 to 132 dB and were given at frequencies of 25. 50 and 63 Hz. The patients with Meniere's disease displayed increased body sway during stimulation. In the individual response. 26% of the patients with Meniere's disease experienced significant body sway. The results demonstrate that subjects with Meniere's disease are sensitive to low frequency sound. The activation of vestibulo-spinal responses by low frequency sound seems to be a result of the Tullio phenomenon. in which sound energy activates the vestibular end-organ.
INTRODUCTION
The Tullio phenomenon is caused by acoustic stimulation of the vestibular part of the labyrinth. Sound waves, by spreading from perilymph to endolyrnph, stimulate the hair cells of the crista ampullaris and induce nystagmus ( I ). The Tullio phenomenon has been considered to be a normal sign of high sound pressure stimulation of the labyrinth. but due to rnethodoiogical faults the data is not conclusive (2). The Tullio phenomenon has been reported with sono-ocular test in patients with Meniere's disease (3) . or in patients with perilymphatic fistula on posturography by means of oscillating sound pressure at frequen- cies of 0.1 and 0.5 Hz (4). In Meniere's disease patients often complain of sound hypersensitivity. The effect of postural stability was examined in patients with Meniere's disease and compared with healthy subjects.
MATERIAL AND METHODS
Recordings were made in 55 healthy volunteers. The subjects were exposed to LFS stimulation in both ears simultaneously. The mean age of subjects was 33.8 years (range 18-55 years). Fifty patients with Meniere's disease (mean age 47.2 years. range 22-77 years) were examined. The low frequency sound was generated with a piston air sampling pump (MSA, USA) which has an adjustable stroke frequency ranging from 25 to 63 Hz. The frequencies used in the test were 2 5 , 50. 63 H z at a constant sound pressure level of 130, 132, 132 dB, respectively. The quiet stance was recorded after initial sway stabiliza- tion during a 30-s period in nonvisual condition. The measuring equipment as composed of a stimulator unit driven by a computer and a measuring system that collects analyses and provides the posturography data off line within a few minutes ( 5 ) . In posturography, a force platform technique was used. The differences between the healthy controls and patients were tested with one way analysis of variance. In pairwise comparison. the significance of the difference was tested with Student's /-test. then in the second stage. with multiple f-test (6).
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SWAY VEL.
MENIERE'S DISEASE 2
Fig. I . Response of low fre- quency sound. (Postural sta- bility was evaluated at mean sway velocity between healthy subjects with bilater- al stimulation and patients with Meniere's disease.)
-----+ _----- ----* HEALTHY SUBJECTS ~ ____--- ---@-----
0 BASE 1 ST 2 SD 3 RD
STIMULATION PERIODS
RESULTS
The normal subjects improved their postural stability during LFS-stimulation. In controls. the difference between stimulation and base line stance was statistically highly significant (p<O.OOI). In pairwise comparisons. we found significant differences between baseline conditions and 50 Hz stimulation period ( p < O . O O I ) as well as 63 Hz stimulation period (p<0.05). The patients had abnormal body sway velocity already during the baseline recording and stimulation with LFS further increased the postural instability. When compared with the controls. the body sway in patients with Meniere's disease during baseline recording was significantly increased ( p < O . O O I I . The responses in patients did not depend on frequency, and already at the lowest stimulation frequency the body sway was significantly increased (Fig. 1 ).
The patients were classified as pathological when 2 or 3 velocity ratios of body sway (sway velocity at different perturbation/sway velocity at baseline) exceeded 95 % confi- dential rate of normal values. Positive responses were shown in 26% of the patients with Meniere's disease.
DISCUSSION
Tullio observed that a loud sound could induce nystagmus and vertigo in some cases. These phenomena have been confirmed thereafter by several authors (7). The sound pressure level at audible frequencies necessary to produce such effects in normal subjects has been estimated to be more than 130 dB. In the present study. the response to the LFS was exposed and normal subjects were compared with patients with vestibular and cochlear lesions to low frequency sound at different frequencies: 35. 5 0 and 63 Hz. The sound pressure level was from 130 to 132 dB. The normal subjects improved their postural stability during LFS-stimulation probably through alerting response. Patients with Me- niere's disease responded to LFS-stimulation increased body sway. The Tullio phenom- enon was originally thought t o reveal a fistula in the bony labyrinth. According to Kwee (8). the most effective sound is 600 Hz at the intensity of I10 dB to 130 dB. Parker reported that nystagmus can occur in normal subjects following exposure to pure tone sound ranging from 200 to 2500 Hz at SPL of 120 to 160 d B (9). Nevertheless, Erlich & Lawson reported that the Tullio phenomenon may be a normal response to exposure of loud sounds (2). Despite of high intensity of sound in the present experiment. normal sub.jects did not observe postural instability to LFS-stimulation. Thus the present observations
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Tullio phenomenon in patients with Meniere 595
demonstrated that LFS a t the intensity of 130-132 d B at frequencies of 25. 50. 63 Hz did not lead to postural instability. T h e Tullio Phenomenon w a s originally considered t o be pathognomonic in patients with congenital syphilis. T h e explanation for the subjective complaint of vestibular symptoms in response to loud noises. especially as seen with endolymphatic hydrops. may be related t o the presence of vestibular fibrosis (10) in which the threshold of sound transmission t o the vestibule may be lowered. Kacker & Hinch- cliffe have reported in two patients with Meniere 's disease with intact tympanic mem- branes that loud noise induced nystagmus ( I 1 ). Our findings confirmed these observation. We interpret the low frequency sound responses as a sign of the Tullio phenomenon. where sound stimulates the vestibular part of the inner ear . The fact that a positive LFS test is not only prevalent in patients with Meniere's disease but also in other inner ea r diseases (12) confirms the existence of changes in the infralabyrinthine compartments that allow LFS to stimulate vestibular endorgans.
R E F E R E N C E
I. Young ED. Fernandez C. Goldberg JM. Responses of squirrel monkey vestibular neurons to audio-frequency sound and head vibration. Acta Otolaryngol (Stockh) 1977: 84: 352-60.
2. Erlich MA. Lawson W. The incidence and significance of the Tullio phenomenon. Otol Head Neck Surg 1980: 8: 630-5.
3. Watanabe 1. Ishida H. Okubo J. Nakamura H. Influence of pressure loading t o the external auditory canal on standing posture in normal and pathological subjects. Adv Otorhinolaryngol 1988: 42: 72-6.
4. Black OF, Lilly DJ, Nashner LM. Peterka RJ . Qantative diagnostic test for perilymph fistulas. Otolaryngol Head Neck Surg 1987: 96: 13-34,
5. Aalto H. Pyykko I. Starck J. Computerized posturography. a development of the measuring system. Acta Otolaryngol (Stockh) 1988; Suppl 449: 71-5.
6. Cox DR. Hinkley DV. Theoretical statistics. London: Chapman & Hall. 1974: 76-82. 7. Pyykko I , Magnusson M. Matsuoka I. Ito S. Hinoki M . Effects of pure tone sound. impulse noise.
8. Kwee HL. The occurrence of the Tullio phenomenon in congenitallv deaf children. J Laryngol
9. Parker DE. Gierge HE. Retschke M. Studies of acoustical stimulation of the vestibular system.
10. Nadol JB. Positive Hennebert's sign in Meniere's disease. Arch Otolaryngol 1977: 103: 5 2 6 3 0 . I I . Kacker SK. Hinchcliffe R. Unusual Tullio phenomenon. J Laryngol 1970: 84: 155-60. 12. Ishizaki H, Pyykko I , Aalto H, Starck J . Tullio phenomenon and postural stability. An expen-
mental study in normal subjects and in patients with vertigo. Ann Otol Rhino1 Laryngol 1990, in press.
and vibration on visual orientation. Am J Otolaryngol 1982: 3 : 104-1 I.
Otol 1976; 90: 501-7.
Aerospace Med 1968; 39: 1321-25.
Address for correspondence: Hisayoshi Ishizaki. Department of Otolaryngology. Hamamtsu Univer- sity School of Medicine, Hamamatsu. 43 1-31 Japan
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