[Diagnostic criteria for Menière's disease according to the Classification Committee of the Bárány Society]. / M. Menière: Diagnostische Kriterien des Internationalen Klassifikationskomitees der Bárány-Gesellschaft.

This paper presents diagnostic criteria for Menière's disease jointly formulated by the Classification Committee of the Bárány Society, The Japan Society for Equilibrium Research, the European Academy of Otology and Neurotology (EAONO), the Equilibrium Committee of the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) and the Korean Balance Society. The classification includes two categories: definite Menière's disease and probable Menière's disease. The diagnosis of definite Menière's disease is based on clinical criteria and requires the observation of an episodic vertigo syndrome associated with low- to medium-frequency sensorineural hearing loss and fluctuating aural symptoms (hearing, tinnitus and/or fullness) in the affected ear. Duration of vertigo episodes is limited to a period between 20 min and 12 h. Probable Menière's disease is a broader concept defined by episodic vestibular symptoms (vertigo or dizziness) associated with fluctuating aural symptoms occurring in a period from 20 min to 24 h.

Anterior subannular T-tube for prolonged middle ear ventilation during tympanoplasty: evaluation of efficacy and complications.

OBJECTIVE: We previously described the use of anterior subannular T-tubes (n = 20) for long-term middle ear ventilation. In the current study, we examine a larger patient population (n = 38) and a longer follow-up interval (average >2 years) to evaluate the efficacy and safety of anterior subannular tympanostomy. STUDY DESIGN: Retrospective nonrandomized case review. SETTING: Tertiary referral hospital. PATIENTS: Our series consisted of 38 consecutive patients with a diagnosis of eustachian tube dysfunction, adhesive otitis media, or chronic otitis media with a perforation who underwent a tympanoplasty. INTERVENTION: A subannular T-tube was placed anteriorly at the time of tympanoplasty to provide long-term middle ear ventilation. MAIN OUTCOME MEASURES: The main outcomes of this study are tube position, tube patency, and middle ear ventilation. In addition, hearing was evaluated both preoperatively and postoperatively and any complications were noted. RESULTS: There were 38 patients and 38 ears that received an anterior subannular T-tube at the time of tympanoplasty. The study group consisted of 24 female patients and 14 male patents with a median age of 36 years (range, 10-75 yr). All 38 patients had eustachian tube dysfunction, 22 had adhesive otitis media, 23 had chronic otitis media, 13 had a cholesteatoma, 11 had tympanic membrane perforations, and 3 patients had a cleft palate. All patients underwent tympanoplasty. Eighteen patients had a concomitant ossiculoplasty and 7 had a mastoidectomy. Follow-up ranged from 1 month to 48 months (average, 26 mo). Three tubes had extruded within 2 years, in 1 case resulting in a persistent perforation. Postoperative complications included 1 patient with a partially extruded prosthesis, 2 patients with tipped prosthesis and persistent tympanic membrane retraction, and 1 patient with a plugged tube. All other tubes were patent and showed no evidence of migration. Furthermore, there were no cases of anterior canal blunting or ingrowth of epithelium around the tube. CONCLUSION: Anterior subannular tympanostomy is a safe and effective method for long-term middle ear ventilation in patients with chronic eustachian tube dysfunction.

Anatomic considerations in vestibular neuritis.

HYPOTHESIS: The authors believe that anatomic differences render the superior division of the vestibular nerve more susceptible to injury during vestibular neuritis. The purpose of the study was to investigate anatomic differences between the superior vestibular nerve and singular nerve canals. BACKGROUND: Previous studies of temporal bones have revealed vestibular nerve degeneration in patients with vestibular neuritis. Although the cause of this degeneration has not been established, it has been noted that the superior division of the vestibular nerve is preferentially affected, with sparing of the inferior division. The superior vestibular nerve and the singular nerve, a branch of the inferior vestibular nerve, both pass through canals interlaced with bony networks before reaching the peripheral receptors. METHODS: The authors performed histologic analysis of 40 normal temporal bones randomly selected from their temporal bone library. With a micrometer, measurements were taken of the individual canals. The ratio of the total bony spicule component to the total canal width was obtained for both the superior vestibular nerve and the singular nerve. The length of the canals was also measured. Arteriole:arteriolar canal ratios of the superior vestibular nerve and singular nerve were obtained. RESULTS: The bony channel of the singular nerve had an average length of 0.59 mm, and the average length of the superior vestibular nerve was 2.30 mm (p < 0.001). The ratio of total bony spicule width to total canal width was significantly smaller (p < 0.05) for the singular nerve (0.30 mm) compared with the superior vestibular nerve (0.34 mm). The arteriole: arteriolar canal ratio was significantly smaller (p < 0.05) for the singular nerve (0.45 mm) than for the superior vestibular nerve (0.54 mm). CONCLUSION: The bony canal of the superior vestibular nerve is longer than the singular nerve canal. Additionally, the superior vestibular nerve and arteriole travel through a relatively narrower passage than the singular nerve and its vascular supply. From an anatomic standpoint, this renders the superior division of the vestibular nerve more susceptible to entrapment and possible ischemic labyrinthine changes.

The ten-minute examination of the dizzy patient.

Dizziness and postural instability are common presenting complaints in patients seen in otolaryngology practice. Unfortunately, these patients frequently do not receive optimal evaluation and therapy because of the difficulty in obtaining a thorough yet pertinent history and the perceived complexity of the physical examination. Over the last 10 years, we have utilized a standardized approach to evaluation of the dizzy patient that is user friendly and maximizes the time and effort spent by the clinician. First, a thorough history is taken from the patient in two forms: (1) a specially designed questionnaire filled out well before the examination and (2) a direct interview using the answers on the questionnaire as a guide. During the physical examination, emphasis is placed on the following subtests: (1) spontaneous nystagmus; (2) central oculomotor function; (3) the vestibulo-ocular reflex (VOR) battery--headshake, head thrust, dynamic visual acuity, and Hallpike positioning; (4) coordination; (5) posture; (6) gait; and (7) special examinations. This neurotologic examination is completed in about 10 minutes and is performed as a battery of tests following the routine otolaryngologic and/or neurologic examination. We feel that this test sequence is thorough yet easy to perform and ideally will demystify the examination of these challenging patients.

Management options for acute versus chronic vertigo.

Optimal management of the dizzy patient depends on an accurate diagnosis and knowledge of medical, surgical, and rehabilitative options. Acute vertigo may represent labyrinthine dysfunction treated with medication or a more serious central nervous system process requiring prompt intervention to avoid long-term disability. Chronic vertigo, however, may require surgical or rehabilitative measures for lasting relief. This article outlines the rationale for treating both groups with a variety of therapeutic options.

Manual rotational testing of the vestibulo-ocular reflex.

OBJECTIVES/HYPOTHESIS: Manual whole-body and head-on-body rotational testing of the vestibuloocular reflex (VOR) is comparable to conventional rotary chair methods with and without visual fixation from 0.025 to 1 Hz. STUDY DESIGN: Summary of four previously published trials from our laboratory and a fifth prospective blinded study comparing whole-body and head-on-body rotation with rotational chair results from 0.025 to 1 Hz in 10 patients with bilateral vestibular dysfunction. METHODS: Subjects were fitted with standard electro-oculogram (EOG) electrodes and placed in the rotary chair for testing at 0.025, 0.05, 0.1, 0.25, 0.5, and 1 Hz in the dark (VOR) and in the light with a stationary target (VVOR). They were then placed in an otolaryngology examination, chair where an adjustable headband containing the velocity sensor and an opaque visor were placed on the forehead. Whole-body rotational trials from 0.025 to 1 Hz and both passive and active head-on-body trials from 0.25 to 1 Hz were performed with and without visual fixation. Data from each frequency were analyzed cycle-by-cycle and averaged for gain, phase, and asymmetry. These values were then compared to the results obtained during rotational chair testing. RESULTS: Throughout the five studies, no systematic differences were noted between the manual rotational methods and the rotary chair results. Specifically, no consistent effect of volition or cervico-ocular reflex (COR) enhancement was demonstrated. CONCLUSIONS: Manual rotational testing is a reliable technique for measuring the VOR up to 1 Hz as compared with standard rotary chair methods. Advantages to this technique include portability, lower equipment costs, and potential application up to 6 Hz using head-on-body rotation.

Interlaboratory variability of rotational chair test results II: analysis of simulated data.

Standardization of rotational chair testing across laboratories has not been achieved because of differences in test protocol and analysis algorithms. The Interlaboratory Rotational Chair Study Group was formed to investigate these differences. Its first study demonstrated significant variability in calculated results using actual patient data files. No estimation of accuracy could be made, however, because the "true" values of response parameters were unknown. In this study we used simulated "patient" data files to further explore the differences among analysis algorithms. We found a high degree of agreement and accuracy across laboratories using automated analysis of high signal-to-noise/low-artifact data for gain, phase, and asymmetry. Variability increased significantly for the lower signal-to-noise ratio/higher artifact files. Operator intervention generally improved accuracy and decreased variability, but there were cases in which operator intervention reduced accuracy.

Approach to the vestibular patient and driving: A patient perspective.

OBJECTIVES: To learn about the impact of dizziness on driving from a patient perspective and to present an approach to the vestibular patient and driving. DESIGN: An anonymous questionnaire completed by 265 dizzy patients at 3 different centers. RESULTS: The participants were experienced drivers who needed to drive to function normally (83%). Those with constant or severe dizziness comprised a higher risk group of drivers. Although few had ever been warned not to drive, 52% said that if they were warned to stop driving, they would not. Most thought that it was the doctor's role to report unsafe drivers to the authorities (P < 0.001, chi2 = 87.2670). CONCLUSIONS: The diagnosis of a vestibular disorder should not alone be grounds to suspend a patient's driver's license. Legislation should be amended to better reflect the views of doctors and patients alike.

Anterior subannular T-tube for long-term middle ear ventilation during tympanoplasty.

OBJECTIVE: A technique for providing long-term ventilation of the middle ear (ME) during tympanoplasty is described, and the results using this technique in 20 patients with chronic Eustachian tube dysfunction (ETD) are reported. STUDY DESIGN: This study was a retrospective, nonrandomized case review. SETTING: This study was conducted at an otology clinic in a tertiary referral center. PATIENTS: Twenty consecutive patients who underwent tympanoplasty with ETD, adhesive otitis media, or chronic otitis media with perforation were included in this study. INTERVENTION: All patients had a subannular T-tube placed anteriorly at the time of tympanoplasty for long-term ventilation of the ME space. MAIN OUTCOME MEASURES: The two main outcome measures were tube position and patency. Preoperative and postoperative hearing levels were also tested in most patients, and any complications were documented. RESULTS: Twenty patients (20 ears) received anterior subannular T-tubes at the time of tympanoplasty. Fourteen females and 6 males were evaluated (median age, 36 years; range, 7 to 72 years). All patients had ETD; 7 had adhesive otitis media, 10 had chronic otitis media, 8 had cholesteatoma, and 2 had cleft palate. All patients had conductive hearing loss and previous surgery. All patients underwent tympanoplasty; 11 had concomitant ossiculoplasty, and 5 had mastoidectomy. Follow-up ranged from 8 to 22 months (mean, 13.4 months). One patient was lost to follow-up. One tube extruded after 16 months. Two patients had persistent mild retraction of the tympanic membrane. All other tubes are patent and have not migrated or plugged. There has been no evidence of anterior blunting or ingrowth of epithelium around the tube. CONCLUSIONS: Anterior subannular T-tube placement is a simple, safe, and effective alternative for long-term ME ventilation in patients in whom standard transtympanic sites are not available. At their last follow-up visit, all but one patient had a patent tube. All MEs were aerated. This technique offers the advantage of ease of placement during simultaneous tympanoplasty, mastoidectomy, or ossiculoplasty. Longer follow-up is necessary to confirm these initial findings.

Comparison of manual whole-body and passive and active head-on-body rotational testing with conventional rotary chair testing.

New methods of rotational testing of the vestibulo-ocular reflex (VOR) using manually generated or patient-generated sinusoidal head movements have recently been advocated for clinical use in circumstances where conventional rotary chair testing methods are not feasible. However, studies seeking to provide evidence for the validity of these methods by comparing their results with an accepted "gold-standard" have been conspicuously absent in the literature. In this study, we compared results for VOR gain, phase, and asymmetry obtained using whole-body and head-on-body rotational stimuli with those obtained by conventional rotary chair testing in 35 subjects with either unilateral or bilateral vestibular deficits over the range of frequencies from 0.025 Hz to 1 Hz. Our results provide evidence for the validity of manual whole-body and active and passive head-on-body rotational testing methods by demonstrating excellent agreement between each of these and conventional rotational chair testing for VOR gain, phase, and asymmetry within the frequency range studied. Small differences at specific-paradigm datapoints are likely secondary to subtle limitations of our experimental design. With further refinement, we expect the new methods will be useful adjuncts for evaluating patients with vestibular complaints in selected clinical situations.

Posturographic evidence of nonorganic sway patterns in normal subjects, patients, and suspected malingerers.

During the last 10 years, computerized dynamic posturography has yielded various patterns of sway on the sensory organization test and the motor control test that have been associated with a variety of organic balance disorders. Some aspects of performance during computerized dynamic posturography, however, are under conscious control. Voluntary movements not indicative of physiologic response to balance system stimulation can also affect computerized dynamic posturography results. Quantification of nonorganic or "aphysiologic" response patterns in normal subjects, patients, and suspected malingerers is crucial to justify use of computerized dynamic posturography for identification of physiologically inconsistent results. For this purpose the computerized dynamic posturography records of 122 normal subjects, 347 patients with known or suspected balance disorders, and 72 subjects instructed to feign a balance disturbance were critically evaluated by use of seven measurement criteria, which were postulated as indicating aphysiologic sway. Each criterion was scored with a standard calculation of the raw data in a random, blinded fashion. The results of this multicenter study show that three of the seven criteria are significantly different in the suspected "malingerer" group when compared with either the normal or patient group. The relative strength of each criterion in discerning organic from nonorganic sway provides the examiner with a measure of reliability during platform posture testing. This study demonstrates that computerized dynamic posturography can accurately identify and document nonorganic sway patterns during routine assessment of posture control.

Idiopathic bilateral vestibular loss.

We describe the clinical and laboratory features of 13 patients with bilateral loss of peripheral vestibular sensitivity of no known cause. In the office, screening for this condition was possible using illegible e-testing and examination of the patient for refixation saccades after brisk head movements while attempting visual fixation. Diagnosis was confirmed by bilaterally reduced caloric responses (< 20 degrees/second on all 4 caloric irrigations) and abnormally low gain of the vestibulo-ocular reflex on rotational chair testing. The mean age of the patients was 68 years. We noted two patterns of symptom onset: onset associated with vertigo (10 patients) and insidious progressive disequilibrium not associated with vertigo (3 patients). Only 38% of the patients complained of subjective oscillopsia. The subjects performed poorly on platform posturography, particularly when deprived of visual and somatosensory feedback. When associated with vertigo, bilateral vestibular loss may be the result of bilateral sequential vestibular neuritis; when not associated with vertigo, disequilibrium may be caused by slow, symmetrical loss of peripheral function as a result of aging. Although the subjects in this report were elderly, idiopathic bilateral vestibular loss has been reported in patients of all ages.

Head slippage during broad-frequency rotational chair testing.

Broad-frequency rotational chair testing is employed in clinical and research settings to evaluate the response of the vestibulo-ocular reflex (VOR) over a range of frequencies. Accurate computation of the gain and phase of the VOR is dependent upon the assumption that the subject's head is rigidly coupled to the rotating chair over the range of frequencies employed. We tested this assumption by examining head slippage in 20 normal subjects using a standard rotational chair over the frequency range 0.025 to 2 Hz. Measurements were made with the subjects' head optimally restrained according to our standard clinical protocol and with the head minimally restrained. Head slippage was expressed as gain and phase of the head with respect to the chair. Computation of these parameters was made by comparing the signal received from a biteblock-mounted rate sensor rigidly coupled to the skull with that of the chair's tachometer. We found highly significant slippage of the head with respect to the chair occurred at 0.5, 1 and 2 Hz, even with the head optimally restrained, leading to increased gain and a phase lag. Gain and phase were highly variable for both conditions at 2 Hz indicating inadequate head fixation using our methods. Below 0.5 Hz, minimal head slippage occurred whether the head was restrained or simply rested against a contoured headrest. Consideration of these results may lead to changing some practices currently employed in broad-frequency rotational chair testing at frequencies of 0.5 Hz and above.

Estrogen replacement therapy and postural stability in the elderly.

Postural instability and falls in the elderly patient constitute a major health care problem. The etiology is often multifactorial, involving abnormal sensory input (visual, vestibular, and somatosensory), poor central processing, and suboptimal musculoskeletal biomechanics. Estrogen replacement therapy has been shown to prevent Alzheimer's disease and to improve cognitive performance in women with dementia. It was, therefore, postulated that estrogen replacement may improve central processing speed, which would result in improved postural stability. In this prospective, randomized, double-blinded study, 87 elderly female subjects (age > 69) were examined by repeated dynamic platform posturography, to measure the effect of estrogen therapy versus placebo upon postural stability. Results indicate that those receiving estrogen had no significant improvement in postural stability at 2 and 8 months of treatment relative to those receiving placebo. Trail Making B test was used as the psychometric test of central processing speed. There was no significant effect of estrogen on this measure over the 8 months of observations. It is concluded that 8 months of estrogen replacement therapy has no significant effect on central processing speed or postural stability in a healthy older female population.

Postural stability following mild head or whiplash injuries.

Studies of the sequelae of head injury suggest that cochlear and vestibular dysfunctions, comprise some of the most frequently reported delayed complications following head trauma. To date, little attention has been given to the relation between post-traumatic subjective symptoms of dizziness and the objective measures of postural stability or balance. The purpose of this study was to quantify the balance deficits in individuals who had developed symptoms of dizziness following mild head and whiplash injuries. The balance abilities of 29 patients, who developed dizziness following some type of mild head or whiplash injury, were compared to those of 51 healthy symptom-free subjects. Balance was assessed by examining the center-of-pressure movements, in the anterior-posterior and medial-lateral directions, and the total movement displacement. The isolated contributions of visual and somatosensory inputs were estimated by comparing the magnitudes of the center-of-pressure movements for the various sensory conditions. Data were collected from three 30-second trials of each combination of three visual conditions (accurate, absent, and inaccurate) and two somatosensory conditions (accurate and inaccurate), with the patient standing on a fixed-force platform. Univariate analyses of variance indicated that the group with head injury, compared to the control group, exhibited significantly greater anterior-posterior movements in four of the six sensory conditions and greater total movement displacement during the inaccurate vision/inaccurate somatosensation condition. These data suggest that patients who have sustained head or neck trauma exhibit increased reliance on accurate visual input and are unable to utilize vestibular orienting information to resolve conflicting information from the visual and somatosensory systems.

Head-shake vestibulo-ocular reflex testing: comparison of results with rotational chair testing.

The currently accepted "gold standard" for rotational testing of the vestibulo-ocular reflex uses a servo-controlled chair for sinusoidal whole-body rotation. Previous work in our laboratory has shown good concordance between conventional rotational chair testing and head-on-body (or "head-shake") testing for gain and phase values of the vestibulo-ocular reflex as recorded and analyzed on our rotational chair system's software. In this article we describe results obtained from 10 normal subjects and 20 patients with reduced caloric responses using a portable system being developed in our laboratory that allows an examiner to generate both whole-body and head-on-body rotational stimuli. Test frequencies within the range 0.25 to 1.0 Hz were chosen for comparison with results obtained by conventional rotational chair testing. Visual conditions for all tests included both visually enhanced vestibulo-ocular reflex (real earth-fixed target) and mentally enhanced vestibulo-ocular reflex (imagined earth-fixed target, in darkness or with vision obscured) paradigms. Our results show general agreement between head-shake and rotational chair testing and both manual whole-body rotation and head-shake testing on our portable system for vestibulo-ocular reflex gain and phase testing, with the largest differences noted at 1.0 Hz. Portable rotational testing was well tolerated by young and elderly subjects alike. We expect manual whole-body rotation and head-shake testing will be useful adjuncts for examining vestibulo-ocular reflex function when more formal rotational chair testing is not possible.

Dose-related effects of alcohol on dynamic posturography and oculomotor measures.

Four healthy male volunteers < 30 years of age participated in a blinded study of placebo versus low (0.45 g/kg lean body weight = LBW), medium (0.80 g/kg LBW) and high (1.05 g/kg LBW) dose ethanol ingestion to investigate its effect upon gaze and posture control. Serial electronystagmography and computerized platform posturography were performed at different points along each subject's blood alcohol concentration (BAC) curve as measured by breath analysis. Smooth pursuit and positional testing revealed subtle abnormalities at sub-intoxicating BACs. In addition, instability on posturography was evident on the Sensory Organization Test with no statistically significant influence observed on muscle latency testing as determined by sway analysis. We conclude that even low ethanol BAC levels produce widespread gaze and posture control effects which can be easily documented.

Test-retest reliability of high-frequency thresholds at bedside with sensorineural hearing-impaired listeners.

Previous investigations have established the reliability of high-frequency thresholds performed in a sound suite using headphones. In addition, test-retest reliability of high-frequency thresholds in adults with normal hearing in a hospital room versus a sound-treated booth has also been established. The current study evaluated the test-retest reliability of thresholds in the 8000- to 18000-Hz range in 15 hearing-impaired adults (26 ears) with varying degrees of sensorineural hearing loss. A high-frequency audiometer and supra-aural earphones were used to measure thresholds in a typical hospital room. Results revealed no significant difference between repeated threshold measures. This study represents the third phase of an ongoing project to develop reliable bedside monitoring of patients undergoing ototoxic medical treatment.