Ocular counter-rolling in scuba divers with motion sickness.

OBJECTIVE: Motion sickness (MS) is a familiar condition to scuba divers. The purpose of this study was to compare otolith organ function of scuba divers who have MS to those without MS. METHOD: Video-oculography (VOG) goggles were used to measure video ocular counter-roll (vOCR) in 50 healthy scuba divers with no vestibular pathology. Divers with MS (n = 30) had Graybiel motion sickness (GMS) scores of ≥1 point, and divers without MS (n = 20) had GMS scores of 0. Divers with MS also completed the Motion Sickness Susceptibility Questionnaire short form (MSSQs). For all divers, otolith-ocular function of both ears was tested separately via vOCR testing, which was performed during 30° head tilt. An R-L side asymmetry ratio for vOCR values (%OCRA) was compared to divers' static OCR. RESULTS: MSSQs and %OCRA scores differed significantly (p<0.01and p<0.001, respectively) between divers with MS and divers without MS. Their %OCRA scores and severity of MS were significantly correlated. Female divers were more susceptible to MS. ROC analysis for %OCRA revealed that the AUC for divers with MS and divers without MS was 0.8967 (95% CI, 0.8114 to 0.9819), the specificity was 1.000, and the sensitivity was 0.700, with a cutoff value of 45.946. CONCLUSION: Physiological differences between R-L otolith organ function could affect the severity and susceptibility to MS. Female hormones may also increase susceptibility to MS. Thus, MS may be a physiological phenomenon induced by functional ear differences in the absence of pathology. As MS is caused by multiple factors, otolaryngologists need to consider various causative factors beyond those related to otolith organ function in scuba divers with MS.

Superior canal dehiscence syndrome associated with scuba diving.

A 28-year-old female diver presented with dizziness and difficulty clearing her left ear whilst scuba diving. Her pure-tone audiometry and tympanometry were normal. Testing of Eustachian tube function revealed tubal stenosis. Video-oculography revealed a predominantly torsional nystagmus while the patient was in the lordotic position. Fistula signs were positive. High-resolution computed tomography (HRCT) of the temporal bone revealed a diagnosis of bilateral superior semicircular canal dehiscence (SCDS). Cervical vestibular-evoked myogenic potential (cVEMP) testing showed that the amplitude of the cVEMP measured from her left ear was larger than that from the right. In electronystagmography (ENG), nose-pinched Valsalva manoeuvres caused eye movements to be mainly directed counterclockwise with a vertical component. Tullio phenomenon was also positive for both ears. SCDS patients tend to be misdiagnosed and misunderstood; common misdiagnoses in these cases are alternobaric vertigo (AV), inner ear barotrauma, and inner-ear decompression sickness. It is difficult to diagnose vertigo attacks after scuba diving as SCDS; however, when the patient develops sound- and/or pressure-induced vertical-torsional nystagmus, HRCT should be conducted to confirm a diagnosis of SCDS.

Quantitative analysis of inner-ear barotrauma using a Eustachian tube function analyzer.

OBJECTIVES: We investigated the relationship between Eustachian tube function and incidence of inner-ear barotrauma (IEBt) in recreational divers. METHODS: Sixteen patients who experienced a scuba diving injury affecting the inner ear and 20 healthy volunteers who had not experienced a diving injury participated. Healthy volunteers and divers with IEBt received impedance tests regularly to assess Eustachian tube function. Test results from these groups were compared. RESULTS: There were no significant differences between test results of IEBt divers and healthy volunteers. However, seven IEBt divers were judged to have irregular compliance curves on impedance testing. Seven of the 16 IEBt divers experienced vertigo. In nearly all of the IEBt divers with vertigo, hearing loss type was manifested as high-tone deafness, and IEBt symptoms appeared during diving. These symptoms were more serious especially when the diving depth was deeper. CONCLUSIONS: To prevent IEBt in scuba divers, we recommend a thorough Eustachian tube function evaluation. Any dysfunction should be treated before engaging in scuba diving. We need to assess more divers who have experienced IEBt and thoroughly examine how their injury happened.

A case of patulous Eustachian tube associated with dizziness induced by nasal respiration.

OBJECTIVE: To determine the relationship between Eustachian tube function and inner ear function in patulous Eustachian tube (pET). METHODS: We encountered a patient with pET accompanied by dizziness that was induced by nasal respiration. Eye movements were recorded using video-oculography, and Eustachian tube function was assessed using a Eustachian tube function analyzer. Horizontal and vertical components of pupil position were assessed to test fixation, positional, and positioning nystagmus. Impedance testing with a Eustachian tube function analyzer was performed to confirm tympanometry results. We recorded these outcomes until the patient's symptoms improved. RESULTS: When pET improved, the patient's symptoms were alleviated. CONCLUSION: The present pET patient had mild vestibular symptoms. Therefore, pET patients with dizziness might be misdiagnosed with, for example, superior semicircular canal dehiscence, psychogenic vertigo, or Ménière's disease. For patients with few clinical symptoms or laboratory findings, clinicians need to consider dizziness-induced pET as a possible diagnosis.

Plasticity of the human vestibulo-ocular reflex during off-vertical axis rotation.

OBJECTIVE: We investigated whether adaptive plasticity of the vestibulo-ocular reflex in humans occurs in response to visual-vestibular conflict stimulation during rotation about a 30° incline (off-vertical earth axis rotation, OVAR). METHODS: Subjects were 26 healthy adults (17 males and 9 females), ranging in age from 22 to 33 years (mean: 24.4) with no history of neurotological symptoms. Each testing session consisted of a pre-test, an adaptation period, and a post-test. The pre-test and the post-test were performed in complete darkness with the subjects' eyes opened. Subjects were rotated sinusoidally at 0.16Hz under OVAR, with a maximum angular velocity of 60°/s for 30s. Subjects were divided into two groups depending on the kind of visual stimulation. One group of subjects was rotated sinusoidally at 0.16Hz and 60°/s peak velocity under OVAR for 20min while viewing optokinetic stripes, which moved at the same frequency and peak velocity as the rotational chair but in the opposite direction (X2 adaptation paradigm). The other group of subjects was rotated sinusoidally at 0.16Hz and 60°/s peak velocity under OVAR for 20min while viewing optokinetic stripes, which moved at the same frequency and peak velocity as the rotatory chair but in the same direction (X0 adaptation paradigm). RESULTS: There was no significant difference in gain before or after adaptation using the X2 adaptation paradigm. VOR gain decreased significantly after adaptation using the X0 adaptation paradigm. CONCLUSION: We hypothesize that attenuation of VOR gain increase after the X2 adaptation paradigm is caused by tilt suppression. In the X0 adaptation paradigm, the decrease in VOR gain was facilitated by tilt suppression in addition to the plastic change of the VOR gain caused by visual-vestibular conflict stimulation. Consequently, the VOR gain change ratio in the X0 adaptation paradigm increased significantly compared to that in the X2 adaptation paradigm.

Altered eustachian tube function in SCUBA divers with alternobaric vertigo.

OBJECTIVES: The number of people participating in sport self-contained underwater breathing apparatus (SCUBA) diving has increased tremendously, bringing with it a rise in diving accidents. Alternobaric vertigo (AV) is a common problem in SCUBA divers. We investigated the relationship between Eustachian tube function and incidence of AV in sport SCUBA divers. We also followed the progress of these divers after Eustachian tube function improved. METHOD: Forty-four patients who experienced a SCUBA diving accident affecting the middle ear (11 men and 33 women; mean ± SD: 37.5 ± 11.5 yr) and 20 healthy volunteer divers who did not experience an accident (6 men and 14 women; mean ± SD: 33.5 ± 13.9 yr) were compared. We divided the divers with an accident into two groups (those with AV vs. those without) and then compared the two groups. All patients regularly underwent Eustachian tube function tests (sonotubometry and impedance test). RESULTS: In sonotubometry and impedance testing, the mean duration (p < 0.001), amplitude (p < 0.002), and maximum air content (p < 0.05) of divers who experienced a diving accident were significantly different from those of healthy volunteers. However, these parameters in divers with AV did not differ significantly from those in divers without AV. In 7 of 15 divers, vestibular symptoms disappeared immediately after ascent. In the remaining eight divers, however, vertigo/dizziness persisted and even was observed at their first clinic visit. CONCLUSION: To prevent AV or barotraumas in SCUBA divers, we recommend a thorough Eustachian tube function evaluation. Any dysfunction should be treated before engaging in SCUBA diving.

Evaluation of the vestibulo-ocular reflex using sinusoidal off-vertical axis rotation in patients with canal paresis.

OBJECTIVE: The vestibulo-ocular reflex (VOR) was studied to determine the utility of off-vertical axis rotation (OVAR) in evaluating vestibular function in patients with canal paresis (CP). Our goal was to determine whether there is any correlation between caloric responses and sinusoidal rotatory responses. METHODS: Subjects were rotated in a sinusoidal pattern with eyes open in complete darkness. Frequencies of 0.4 and 0.8Hz with a maximum angular velocity of 60°/s at either earth-vertical axis rotation (EVAR) or OVAR were used. RESULTS: Twenty-three control subjects and 21 patients with CP were investigated. Results showed that (1) the VOR gain difference between EVAR and OVAR in the CP patients was not significant at 0.4Hz and at 0.8Hz; (2) the gain during 0.4Hz EVAR was less in the bilateral CP patients compared to controls; and (3) the VOR gain of the affected side at 0.8Hz was significantly less during OVAR than during EVAR. CONCLUSION: We concluded that the absence or reduction of caloric responses does not indicate the absence of vestibular function. In addition, separation analysis of the VOR gain of affected and intact sides is useful for evaluating laterality of otolith function in patients with CP.

[A study of the Eustachian tube function in patients with a scuba diving accident].

The scuba diving population has increased very much recently, bringing with it a rise in barotrauma. Ninety-seven patients with scuba diving-related accidents (34 males and 63 females; mean +/- SD: 36.6 +/- 10.3 years) and 39 healthy volunteers (9 males and 30 females; mean +/- SD: 41.1 +/- 16.9 years) without a history of Eustachian tube dysfunction participated in this study. All patients underwent audiometric measurements, including hearing testing, tympanometry, and Eustachian tube function testing (sonotubometry and impedance test). The tympanometry results of the majority of the patients were normal (Jerger A type), however, 83 of 97 patients (85.6%) were diagnosed as having Eustachian tube dysfunction: all patients had tubal stenosis. Compared with healthy volunteers, the Eustachian tube function in scuba diving patients was significantly lower. According to whether the affected parts were one ear or both ears, we classified these patients into 2 types, that is, the unilateral group and the bilateral group. The symptoms in the unilateral group were more serious than those in the bilateral group. In the unilateral group, the Eustachian tube functions of the affected ear did not always show lower than those of the healthy ear, so we thought that excessive positive pressure at the mesotympanum caused by the Valsalva maneuver might have affected not only the affected ear but also the healthy ear and have resulted in healthy ears being severely impaired by excessive positive pressure. To prevent scuba divers from pressure injury, we think that divers should have their Eustachian tube dysfunction accurately evaluated and any problems should be treated well.

Does vertigo disappear only by rolling over? Rehabilitation for benign paroxysmal positional vertigo.

CONCLUSION: We propose that the rolling-over maneuver (ROM) is as effective as the canalith repositioning maneuver (CRP) for the treatment of benign paroxysmal positional vertigo (BPPV). ROM involves easy movements, with only a small load. This therapy is suitable for most BPPV patients, even for those without an indication for CRP. OBJECTIVES: BPPV is a common vestibular disorder. CRP is known to be an effective therapy for the treatment of BPPV. Because of its various movements of the head and body, it is impossible to perform CRP in BPPV patients with orthopedic impairments or in the elderly. For these patients, we perform a maneuver called ROM, which involves easy movements. In this study, we compared the efficacy of ROM with that of CRP in patients with posterior semicircular canal-type BPPV. PATIENTS AND METHODS: The study included 22 patients with BPPV who were randomized and divided into the following 2 groups: 1) those treated by the modified Epley maneuver as CRP; and 2) those treated by ROM. RESULTS: We found no significant difference between the two groups in the number of days from onset to remission of both nystagmus and vertigo.

Neuro-Behçet's disease with dizziness.

A 30-year-old man had complete-type Behçet's disease since he was 23 years old. Disease signs and symptoms were well controlled. After experiencing no symptoms for some years, however, he experienced dizziness, headache, fever, dysarthria, right facial nerve palsy, and right tinnitus. He showed spontaneous horizontal-rotatory nystagmus directed toward the right side, and upbeat nystagmus. T2-weighted and fluid-attenuated inversion recovery MRI showed slight hyperintense signals in the medulla oblongata, pons, and left midbrain. Neurological involvement in Behçet's disease was diagnosed.

[Ramsay Hunt syndrome with cranial polyneuropathy involving cranial nerves VII, VIII, IX, and X].

In addition to facial and vestibular nerve paralysis, patients with Ramsay Hunt syndrome may also show glossopharyngeal, vagal, and hypoglossal nerve paralysis. We report a case of Ramsay Hunt syndrome with cranial polyneuropathy including cranial nerves VII, VIII, IX, and X. A 58-year-old rheumatic woman suffering from vertigo, right earache, and sore throat suffered right-side facial palsy, hoarseness, and swallowing difficulty on day 5. Admitted on day 6, she was treated with antiviral medication and steroids. Although vertigo, facial palsy, and hearing loss gradually improved, hoarseness required over three months to recover. Of the 33 patients with Ramsay Hunt syndrome we have seen, 9 (27%) had cranial polyneuropathy, including cranial nerves IX and X in 4 years. Of these, 9% involved total paralysis of nerves IX and X. Physical symptoms of those with polyneuropathy, especially vagal nerve palsy, tended to worsen, making it important to observe other cranial nerve signs, such as for IX and X carefully, in addition to VII and VIII.

Somatosensory input influences the vestibulo-ocular reflex.

To evaluate the influence of somatosensory input on the vestibulo-ocular reflex (VOR), we used sinusoidal rotation tests in 19 young, healthy volunteers. For the control condition, subjects were sinusoidally rotated in complete darkness and with eyes opened at a frequency of 0.2 Hz with a maximum angular velocity of 30 degrees /s for 30s, and at frequencies of 0.4 and 0.8 Hz with a maximum angular velocity of 60 degrees /s for 30s. Sinusoidal tests were performed at earth vertical axis rotation (EVAR). For the experimental condition, we introduced somatosensory stimulation as subjects were sinusoidally rotated at the control parameters. Subjects were told to grasp an earth-fixed metallic bar with their right hands. Thus, their right arms continued to move as the rotating chair apparatus moved. We observed a significant increment (34%) in VOR gain change only at 0.2 Hz EVAR when subjects held the bar compared to that of the controls, who did not hold the bar. Gain change did not differ significantly across the other conditions. We hypothesize that arthrokinetic input (i.e., arm movement) had an additive effect on VOR in this study. This input might relate to a low-frequency component that strongly enhances the velocity storage system. Our findings have applications to types of vestibular rehabilitation regimens that implement somatosensory input.

Evaluation of the vestibulo-ocular reflex using sinusoidal off-vertical axis rotation in patients with acoustic neurinoma.

The vestibulo-ocular reflex (VOR) was studied to examine the utility of off-vertical axis rotation (OVAR) in the diagnosis of acoustic neurinoma. Subjects were sinusoidally rotated with eyes open in complete darkness at frequencies of 0.4 and 0.8 Hz with a maximum angular velocity of 60 degrees /s at either earth-vertical axis rotation (EVAR) or OVAR. Thirteen patients with acoustic neurinomas were investigated. Results showed that VOR gain during OVAR at 0.8 Hz and in a 30 degrees nose-up position in patients with internal auditory canal tumors was significantly less than the gain measured during EVAR. The VOR gain measured from all patients (including those with tumors extending to the cerebellopontine angle) was not significantly different when the patients were subjected to EVAR and OVAR. These observations were possibly due to superior vestibular nerve dysfunction. We concluded that certain stimulating parameters--patient's nose tilted up 30 degrees; sinusoidal OVAR at 0.8 Hz and 60 degrees /s maximum angular head velocity--were useful for evaluating vestibular function in patients suffering from an acoustic neurinoma located within the internal auditory canal.

Properties and axonal trajectories of posterior semicircular canal nerve-activated vestibulospinal neurons.

We studied the axonal projections of vestibulospinal neurons activated from the posterior semicircular canal. The axonal projection level, axonal pathway, and location of the vestibulospinal neurons originating from the PC were investigated in seven decerebrated cats. Selective electrical stimulation was applied to the PC nerve, and extracellular recordings in the vestibular nuclei were performed. The properties of the PC nerve-activated vestibulospinal neurons were then studied. To estimate the neural pathway in the spinal cord, floating electrodes were placed at the ipsilateral (i) and contralateral (c) lateral vestibulospinal tract (LVST) and medial vestibulospinal tract (MVST) at the C1/C2 junction. To elucidate the projection level, floating electrodes were placed at i-LVST and MVST at the C3, T1, and L3 segments in the spinal cord. Collision block test between orthodromic inputs from the PC nerve and antidromic inputs from the spinal cord verified the existence of the vestibulospinal neurons in the vestibular nuclei. Most (44/47) of the PC nerve-activated vestibulospinal neurons responded to orthodromic stimulation to the PC nerve with a short (<1.4 ms) latency, indicating that they were second-order vestibulospinal neurons. The rest (3/47) responded with a longer (>/=1.4 ms) latency, indicating the existence of polysynaptic connections. In 36/47 PC nerve-activated vestibulospinal neurons, the axonal pathway was histologically verified to lie in the spinal cord. The axons of 17/36 vestibulospinal neurons projected to the i-LVST, whereas 14 neurons projected to the MVST, and 5 to the c-LVST. The spinal segment levels of projection of these neurons elucidated that the axons of most (15/17) of vestibulospinal neurons passing through the i-LVST reached the L3 segment level; none (0/14) of the neurons passing through the MVST extended to the L3 segment level; most (13/14) of them did not descend lower than the C3 segment level. In relation to the latency and the pathway, 33/36 PC nerve-activated vestibulospinal neurons were second-order neurons, whereas the remaining three were polysynaptic neurons. Of these, 33 second-order vestibulospinal neurons, 16 passed through the i-LVST, while 13 and 4 descended through the MVST and c-LVST, respectively. The remaining three were polysynaptic neurons. Histological analysis showed that most of the PC nerve-activated vestibulospinal neurons were located within a specific area in the medial part of the lateral vestibular nucleus and the rostral part of the descending vestibular nucleus. In conclusion, it was suggested that PC nerve-activated vestibulospinal neurons that were located within a focal area of the vestibular nuclei have strong connections with the lower segments of the spinal cord and are related to postural stability that is maintained by the short latency vestibulospinal reflex.

Recovery of otolith function in patients with benign paroxysmal positional vertigo evaluated by sinusoidal off-vertical axis rotation.

The vestibulo-ocular reflex (VOR) was studied via sinusoidal off-vertical axis rotation (OVAR) to evaluate otolith function in patients with benign paroxysmal positional vertigo (BPPV). Subjects were sinusoidally rotated with eyes open in complete darkness at frequencies of 0.4 and 0.8 Hz with a maximum angular velocity of 60 degrees /s in earth vertical axis rotation (EVAR) and OVAR. Ten patients with BPPV patients were investigated. We performed OVAR tests for all patients for the following different points and compared otolith function: (1) The point at which patients had typical nystagmus; we call this state 'Before', that is, before recovery. (2) The point when their nystagmus disappeared; we call this state 'After' that is, after nystagmus disappear. Results showed that VOR gain during OVAR at 0.8 Hz in a 30 degrees nose-up position in BPPV patients was significantly less than the gain during EVAR at the point Before. On the other hand, gain was not significantly different between EVAR and OVAR at the point After. VOR gain itself at 0.8 Hz nose-up OVAR showed a significant increase at the point After compared to Before. This increase of VOR gain might be caused by the recovery of the otolith function in patients with BPPV.

Evaluation of the otolith function using sinusoidal off-vertical axis rotation in patients with benign paroxysmal positional vertigo.

The vestibulo-ocular reflex (VOR) was studied via sinusoidal off-vertical axis rotation (OVAR) to evaluate the otolith function in patients with benign paroxysmal positional vertigo (BPPV). Subjects were sinusoidally rotated with eyes open in complete darkness at frequencies of 0.4 and 0.8 Hz with a maximum angular velocity of 60 degrees s(-1) in earth-vertical axis rotation (EVAR) and OVAR. Twenty-three controls and 24 BPPV patients were investigated. Results showed that VOR gain during OVAR at 0.8 Hz in a 30 degrees nose-up position in BPPV patients was significantly less than the gain during EVAR, whereas the gain was not significantly different between EVAR and OVAR in the controls in each condition. In addition, to examine each type of BPPV, we also investigated whether there were any differences between the patients who suffered from dizziness and those who did not. VOR gain in OVAR of BPPV patients who were suffering from dizziness was significantly less than that of BPPV patients without dizziness. Not only cupulolithiasis or canalolithiasis, but also otolith dysfunction was considered to be the possible origin of BPPV. Because sinusoidal OVAR produced minimal nausea compared to constant velocity OVAR, the stimulation of 0.8 Hz nose-up in sinusoidal OVAR may be used to evaluate otolith function without discomfort for patients.

Axonal pathways and projection levels of anterior semicircular canal nerve-activated vestibulospinal neurons in cats.

Using collision tests of orthodromically and antidromically generated spikes, we studied the axonal pathways, axonal projection levels, and soma location of anterior semicircular canal (AC) nerve-activated vestibulospinal neurons in decerebrate cats. AC nerve-activated vestibulospinal neurons (n=74) were mainly located in the ventral portion of the lateral vestibular nuclei and the rostral portion of the descending vestibular nucleus, which is consistent with previous studies. Of these neurons, 15% projected through the ipsilateral (i-) lateral vestibulospinal tract (LVST), 74% projected through the medial vestibulospinal tract (MVST), and 11% projected through the contralateral (c-) LVST. The vast majority (78%) of AC nerve-activated vestibulospinal neurons were activated antidromically only from the cervical segment of the spinal cord; 15% of neurons were activated from the T1 segment and only one neuron was activated from the L3 segment. AC nerve-activated vestibulospinal neurons may primarily target the neck muscles and thus contribute to the vestibulocollic reflex. Most of the c-LVST neurons were also activated antidromically from the oculomotor nucleus, suggesting that they are closely related to the control of combined eye-head movements.