Probabilities of Isolated and Co-Occurring Vestibular Disorder Symptom Clusters Identified Using the Dizziness Symptom Profile.

OBJECTIVES: Dizziness is among the most common reasons people seek medical care. There are data indicating patients with dizziness, unsteadiness, or vertigo may have multiple underlying vestibular disorders simultaneously contributing to the overall symptoms. Greater awareness of the probability that a patient will present with symptoms of co-occurring vestibular disorders has the potential to improve assessment and management, which could reduce healthcare costs and improve patient quality of life. The purpose of the current investigation was to determine the probabilities that a patient presenting to a clinic for vestibular function testing has symptoms of an isolated vestibular disorder or co-occurring vestibular disorders. DESIGN: All patients who are seen for vestibular function testing in our center complete the dizziness symptom profile, a validated self-report measure, before evaluation with the clinician. For this retrospective study, patient scores on the dizziness symptom profile, patient age, and patient gender were extracted from the medical record. The dizziness symptom profile includes symptom clusters specific to six disorders that cause vestibular symptoms, specifically: benign paroxysmal positional vertigo, vestibular migraine, vestibular neuritis, superior canal dehiscence, Meniere disease, and persistent postural perceptual dizziness. For the present study, data were collected from 617 participants (mean age = 56 years, 376 women, and 241 men) presenting with complaints of vertigo, dizziness, or imbalance. Patients were evaluated in a tertiary care dizziness specialty clinic from October 2020 to October 2021. Self-report data were analyzed using a Bayesian framework to determine the probabilities of reporting symptom clusters specific to an isolated disorder and co-occurring vestibular disorders. RESULTS: There was a 42% probability of a participant reporting symptoms that were not consistent with any of the six vestibular disorders represented in the dizziness symptom profile. Participants were nearly as likely to report symptom clusters of co-occurring disorders (28%) as they were to report symptom clusters of an isolated disorder (30%). When in isolation, participants were most likely to report symptom clusters consistent with benign paroxysmal positional vertigo and vestibular migraine, with estimated probabilities of 12% and 10%, respectively. The combination of co-occurring disorders with the highest probability was benign paroxysmal positional vertigo + vestibular migraine (~5%). Probabilities decreased as number of symptom clusters on the dizziness symptom profile increased. The probability of endorsing vestibular migraine increased with the number of symptom clusters reported. CONCLUSIONS: Many patients reported symptoms of more than one vestibular disorder, suggesting their symptoms were not sufficiently captured by the symptom clusters used to summarize any single vestibular disorder covered by the dizziness symptom profile. Our results indicate that probability of symptom clusters indicated by the dizziness symptom profile is comparable to prior published work on the prevalence of vestibular disorders. These findings support use of this tool by clinicians to assist with identification of symptom clusters consistent with isolated and co-occurring vestibular disorders.

Self-Reported Symptoms of Vertigo and Imbalance Are Prevalent Among Adults With Chronic Moderate-Severe Traumatic Brain Injury: A Preliminary Analysis.

PURPOSE: Dizziness and imbalance are common symptoms during the acute phase of traumatic brain injury (TBI). However, there is evidence to suggest that these symptoms persist into the chronic phase of injury. Few prospective studies have examined the frequency and type of dizziness and imbalance in adults with chronic moderate-severe TBI. The aim of this preliminary analysis was to investigate the prevalence of these symptoms in adults with chronic moderate-severe TBI. METHOD: Twenty-four adults with chronic moderate-severe TBI and a group of 19 age-, sex-, and education-matched noninjured comparison participants were recruited. Self-reported dizziness and imbalance were measured using a modified version of a standard case history form. Significant associations between group (TBI group or noninjured comparison [NC] participants) and self-reports of dizziness, imbalance, and related symptoms (endorsed "yes" or "no") were explored. RESULTS: The TBI group most reported lightheadedness (75%), vertigo (38%), and imbalance and/or falling (46%). The most common related symptom reported by the TBI group was headache (63%) and nausea (46%). Significant associations revealed that the TBI group responded "yes" in higher percentages than the NC group across all categories (dizziness, imbalance, and related symptoms). There were no statistically significant relationships among dizziness, imbalance, or headache symptoms within the TBI group. CONCLUSIONS: These preliminary findings suggest that dizziness and imbalance are prevalent in adults with chronic moderate-severe TBI. Persistent vertiginous symptoms may point to an underlying vestibular impairment. However, further research is needed to characterize vestibular function in chronic moderate-severe TBI.

Benefits of Text Supplementation on Sentence Recognition and Subjective Ratings With and Without Facial Cues for Listeners With Normal Hearing.

OBJECTIVES: Recognizing speech through telecommunication can be challenging in unfavorable listening conditions. Text supplementation or provision of facial cues can facilitate speech recognition under some circumstances. However, our understanding of the combined benefit of text and facial cues in telecommunication is limited. The purpose of this study was to investigate the potential benefit of text supplementation for sentence recognition scores and subjective ratings of spoken speech with and without facial cues available. DESIGN: Twenty adult females (M = 24 years, range 21 to 29 years) with normal hearing performed a sentence recognition task and also completed a subjective rating questionnaire in 24 conditions. The conditions varied by integrity of the available facial cues (clear facial cues, slight distortion facial cues, great distortion facial cues, no facial cues), signal-to-noise ratio (quiet, +1 dB, -3 dB), and text availability (with text, without text). When present, the text was an 86 to 88% accurate transcription of the auditory signal presented at a 500 ms delay relative to the auditory signal. RESULTS: The benefits of text supplementation were largest when facial cues were not available and when the signal-to-noise ratio was unfavorable. Although no recognition score benefit was present in quiet, recognition benefit was significant in all levels of background noise for all levels of facial cue integrity. Moreover, participant subjective ratings of text benefit were robust and present even in the absence of recognition benefit. Consistent with previous literature, facial cues were beneficial for sentence recognition scores in the most unfavorable signal-to-noise ratio, even when greatly distorted. It is interesting that, although all levels of facial cues were beneficial for recognition scores, participants rated a significant benefit only with clear facial cues. CONCLUSIONS: The benefit of text for auditory-only and auditory-visual speech recognition is evident in recognition scores and subjective ratings; the benefit is larger and more robust for subjective ratings than for scores. Therefore, text supplementation might provide benefit that extends beyond speech recognition scores. Combined, these findings support the use of text supplementation in telecommunication, even when facial cues are concurrently present, such as during teleconferencing or watching television.

The effect of EMG magnitude on the masseter vestibular evoked myogenic potential (mVEMP).

Introduction: The masseter vestibular evoked myogenic potential (mVEMP) is a bilaterally generated, electromyographically (EMG)-mediated response innervated by the trigeminal nerve. The purpose of the present investigation was to 1) determine whether subjects could accurately achieve and maintain a range of EMG target levels, 2) to examine the effects of varied EMG levels on the latencies and amplitudes of the mVEMP, and 3) to investigate the degree of side-to-side asymmetry and any effects of EMG activation. Methods: Subjects were nine neurologically and otologically normal young adults. A high-intensity tone burst was presented monaurally while subjects were seated upright and asked to match a range of EMG target levels by clenching their teeth. Recordings were made from the ipsilateral and contralateral masseter muscles referenced to the ear being monaurally stimulated. Results: We found that the tonic EMG target had no effect on mVEMP latency. Additionally, although mVEMP amplitudes "scaled" to the EMG target, there was a tendency for the subjects' EMG level to "undershoot" the EMG target levels greater than 50 µV. While some individuals did generate differences in EMG activation between sides, there were no significant differences on average EMG activation between sides. Further, while average corrected amplitude asymmetry was similar across EMG targets, some individuals demonstrated large, corrected amplitude asymmetry ratios. Conclusions: The results of this investigation suggest that, as with cVEMP recordings, the underlying EMG activation may vary between subjects and could impact mVEMP amplitudes, yet could be mitigated by amplitude correction techniques. Further it is important to be aware that even young normal subjects have difficulty maintaining large, tonic EMG activity during the mVEMP recording.

Applying the Hearing Aid Fitting Standard to Selection for Adults.

The recent hearing aid fitting standard for adults outlines the minimum practice for audiologists fitting adult patients with hearing loss. This article focuses on three items of the standard (5, 6, and 7), which focus on the selection of unilateral/bilateral hearing aids, hearing aid style, and coupling, in addition to feature selection. The standard emphasizes that decisions around these three aspects should be recommended for a patient in an individualized manner, based on their needs assessment. For these decisions, the needs assessment might include measures of speech-in-noise ability, social network size, patient preference, and a trial period. Additional elements could include assessments of manual dexterity, binaural interference, and attitude toward hearing aids. However, there are a multitude of ways to practice clinically and still meet the items outlined in the standard. As long as the selection decisions consider individualized patient factors and are capable of meeting validated prescriptive targets, a clinician would be meeting the adult hearing aid fitting minimum standard guidance. In addition, despite the large number of past studies supporting these standards, additional, high-quality research including randomized, controlled, clinical trials are still needed to further support appropriate minimum standard recommendations.

Automated Audiometry in Quiet and Simulated Exam Room Noise for Listeners with Normal Hearing and Impaired Hearing.

BACKGROUND: Up to 80% of audiograms could be automated which would allow more time for provision of specialty services. Ideally, automated audiometers would provide accurate results for listeners with impaired hearing as well as normal hearing. Additionally, accurate results should be provided both in controlled environments like a sound-attenuating room but also in test environments that may support greater application when sound-attenuating rooms are unavailable. Otokiosk is an iOS-based system that has been available for clinical use, but there are not yet any published validation studies using this product. PURPOSE: The purpose of this project was to complete a validation study on the OtoKiosk automated audiometry system in quiet and in low-level noise, for listeners with normal hearing and for listeners with impaired hearing. RESEARCH DESIGN: Pure tone air conduction thresholds were obtained for each participant for three randomized conditions: standard audiometry, automated testing in quiet, and automated testing in noise. Noise, when present, was 35 dBA overall and was designed to emulate an empty medical exam room. STUDY SAMPLE: Participants consisted of 11 adults with hearing loss and 15 adults with normal hearing recruited from the local area. DATA COLLECTION AND ANALYSIS: Thresholds were measured at 500, 1,000, 2,000, and 4,000 Hz using the Otokiosk system that incorporates a modified Hughson-Westlake method. Results were analyzed using descriptive statistics and also by a linear mixed-effects model to compare thresholds obtained in each condition. RESULTS: Across condition and participant group 73.6% of thresholds measured with OtoKiosk were within ± 5 dB of the conventionally measured thresholds; 92.8% were within ± 10 dB. On average, differences between tests were small. Pairwise comparisons revealed thresholds were ∼3.5-4 dB better with conventional audiometry than with the mobile application in quiet and in noise. Noise did not affect thresholds measured with OtoKiosk. CONCLUSIONS: The OtoKiosk automated hearing test measured pure tone air conduction thresholds from 500 to 4,000 Hz at slightly higher thresholds than conventional audiometry, but less than the smallest typical 5 dB clinical step-size. Our results suggest OtoKiosk is a reasonable solution for sound booths and exam rooms with low-level background noise.

Effects of Lifestyle Modification on Vestibular Migraine.

OBJECTIVE: To evaluate effects of lifestyle modification on symptoms of dizziness and headache in patients diagnosed with definite vestibular migraine. STUDY DESIGN: Prospective within-participants repeated-measures study. SETTING: Otolaryngology tertiary care. PARTICIPANTS: Twenty-eight adults with definite vestibular migraine who were willing to be treated without pharmacological intervention. INTERVENTIONS: Information and instructions were provided on lifestyle modification; participants were instructed to improve restful sleep, exercise, eat at regulated mealtimes, and avoid dietary triggers. Participants were asked to maintain the modifications for at least 60 days. MAIN OUTCOME MEASURES: Two self-report inventories were used pre- and post-intervention to evaluate participants' perceived dizziness handicap and headache disability using the Dizziness Handicap Inventory and Headache Disability Inventory, respectively. Questions were also used to evaluate the extent to which participants reported compliance with lifestyle factors pre- and post-intervention. RESULTS: Significant improvement was observed after the lifestyle intervention with mean improvements in Dizziness Handicap Inventory and Headache Disability Inventory of 14.3 points. As a group, improvement in restful sleep was related to improvement in both dizziness and headache symptoms. At the individual participant level, 39% and 18% of participants reported significant reduction in dizziness handicap and headache disability, respectively. CONCLUSIONS: Lifestyle modifications are an effective intervention for symptoms of dizziness and headache in participants with definite vestibular migraine. Participants who reported a larger increase in restful sleep were more likely to also report larger improvements in dizziness handicap and headache disability. Effect sizes using the current intervention were comparable or better than some reported pharmacological interventions but less than others. Our lifestyle modification intervention produced significant improvement in dizziness for a larger percentage of individual participants and in headache for a similar percentage of participants compared to data reported with other lifestyle modification interventions. Lifestyle modifications, especially restful sleep, have the potential to reduce the impact of vestibular migraine on patients' lives, with limited risk.Clinical Trials Registration: NCT03979677.

Case Study: Depersonalization and Vestibular Impairment.

BACKGROUND: We describe herein the case of a patient whose primary complaints were episodic vertigo and "depersonalization," a sensation of detachment from his own body. PURPOSE: This case study aims to further clinical knowledge and insight into the clinical evaluation of vertiginous patients with complaints of depersonalization. RESEARCH DESIGN: This is a case study. DATA COLLECTION AND ANALYSIS: A retrospective chart review of vestibular function testing done on a vertiginous patient with complaints of depersonalization was performed. RESULTS: Vestibular function testing revealed absent cervical and ocular vestibular evoked myogenic potentials on the left side with normal vHIT or video Head Impulse Test, videonystagmography, and rotational chair results, suggesting peripheral vestibular impairment isolated to the left saccule and utricle. CONCLUSION: The otolith end organ impairment explains the patient's postural deviation to the left side during attempts to ambulate. We recommend that clinicians should be attentive to patient complaints of depersonalization and perform vestibular evoked myogenic potential testing to determine whether evidence of at least a unilateral peripheral otolith end organ impairment exists.

Test-Retest Reliability of the Dizziness Symptom Profile.

OBJECTIVES: This investigation was conducted to measure the test-retest reliability of the Dizziness Symptom Profile (DSP). The DSP was developed to assist primary care providers, general otolaryngologists, and other health care providers in the development of a differential diagnosis for patients who present with dizziness, vertigo, or unsteadiness. The DSP yields a score ranging from 0 to 100% for each of 7 subscales. Each subscale represents a different diagnosis including benign paroxysmal positional vertigo, Ménière's disease, persistent postural-perceptual dizziness (PPPD), superior semi-circular canal dehiscence, vestibular migraine, vestibular neuritis, and general unsteadiness. DESIGN: Subjects were 150 adult patients (mean age 56.79 years, SD 15.69 years) referred to the Balance Disorders Clinic at Vanderbilt University Medical Center. Subjects completed two administrations of the DSP. The mean interval between test administrations was 1.58 days (SD 1.78 days). The response modes for the DSP were both a 0 to 100 mm visual analog scale (scored 0 mm = "strongly disagree" to 100 mm = "strongly agree") and, by extrapolation, the original 5-point Likert scale where the anchors were "strongly disagree" (scored 0 points) and "strongly agree" (scored 4 points). RESULTS: Pearson correlation coefficients were calculated to assess test-retest reliability for individual DSP items, and ranged from r = 0.67 to 0.91 (mean 0.80; p < 0.001). Cronbach's α coefficients were calculated to assess internal consistency reliability of items comprising the seven subscales. Each subscale had an acceptable level of internal consistency (Cronbach's α coefficients > 0.7) with the exception of PPPD which approached 0.7. Intraclass correlation coefficient estimates and their 95% confidence intervals were also calculated to assess the relative reliability of the subscales. All 7 subscales showed moderate to strong test-retest reliability, with intraclass correlation coefficients ranging from 0.85 to 0.94. Minimal detectable change (MDC) scores were calculated to assess absolute variability/measurement error for the seven subscale scores (which range from 0 to 100%). MDC values ranged from 16% (PPPD) to 25% (unsteadiness). CONCLUSIONS: (1) The test-retest reliability of the DSP is moderate to strong. (2) MDC values for each subscale were determined. (3) The DSP coupled with the Dizziness Handicap Inventory enables the clinician to evaluate the constructs of dizziness impairment, and disability/handicap. (4) The DSP may help provide a window to the natural history of dizziness disease(s). (5) The DSP provides a less biased assessment of the symptoms reported by the patient.

Multiple Co-Occurring Vestibular Disorders Identified Using the Dizziness Symptom Profile.

Purpose The purpose of the current investigation was to determine the interrelations among vestibular disorders from a data set generated from the patient perspective as compared to previous data generated from the physician's perspective. Method The data for the current investigation originated from a previously published study describing the development of the Dizziness Symptom Profile (DSP; Jacobson et al., 2019). The DSP is a 31-item patient self-report tool designed to help primary care physicians in the development of a differential diagnosis using the patient's level of agreement with each dizziness and symptom-related statement. Responses to these items converge on common vestibular diagnoses and were previously found to agree with ear specialist differential diagnoses 70.3% of the time. Data were collected for 131 subjects (M age = 56.7 years, 72 women) seen for evaluation in a tertiary dizziness specialty clinic. For this study, the data were analyzed using descriptive statistics to determine the frequency of single diagnoses, multiple diagnoses, co-occurring diagnoses, and patterns of co-occurrence. Results Results indicated that 52.7% of patients endorsed a single vestibular diagnosis and 47.3% endorsed two or more vestibular diagnoses. Benign paroxysmal positional vertigo (BPPV) and vestibular migraine were the most common single diagnoses and also the most common co-occurring diagnoses. As the number of diagnoses endorsed on the DSP increased, so did the percentage of time that BPPV and vestibular migraine would occur. Conclusions Results support and extend the work of others but using data generated from the perspective of the patient. A slight majority of patients endorsed a single disorder, but almost as many patients endorsed more than one vestibular diagnosis. BPPV and vestibular migraine were the most common single vestibular diagnoses and also the most common co-occurring vestibular diagnoses; vestibular migraine was more common when multiple diagnoses were endorsed. Results suggest it is common for patients to volunteer symptoms that cannot be explained by a single vestibular diagnosis. This finding is in agreement with physician-generated diagnosis data. Clinicians should consider the possibility of co-occurring diagnoses in complicated patients or in patients who are not responding optimally to management of a single vestibular disorder. The DSP is a tool that encourages clinicians to consider multiple co-occurring vestibular disorders as the source of patient complaints.

A factor analytic assessment of the English translation of the neuropsychological vertigo inventory (NVI).

PURPOSE: Vestibular impairments have been associated with a variety of cognitive deficits, most notably deficits in visuo-spatial memory. The Neuropsychological Vertigo Inventory (NVI) was developed to measure self-reported cognitive deficits in patients with dizziness and/or vertigo. The original French language version of the NVI includes 28 items and 7 subscales. The purpose of the present investigation was to determine whether the statistical assessment of an English language version supported the presence of the same cognitive constructs as the French version of the NVI. METHOD: The English language adaptation of the NVI (referred to here as the NVIe) was administered to an unselected sample of 280 patients that were being evaluated for dizziness and/or vertigo in a tertiary care dizziness clinic. The individual item scores from the NVIe were subjected to an exploratory factor analysis (EFA). RESULTS: The results of the data analysis supported a 22-item NVIe consisting of 4 constructs: affective state, temporal memory, spatial memory, visual spatial cognition. CONCLUSIONS: The NVIe is a new tool for screening cognitive constructs that may be affected by vestibular impairments. Prior to clinical implementation of the NVIe, additional studies of reliability and convergent validity are needed.

Short Communication: The Belly-Tendon Derivation Yields Superior Ocular Vestibular Evoked Myogenic Potential Amplitudes in a Normal Pediatric Sample.

Purpose The purpose of the investigation was to determine whether the "belly-tendon" electrode derivation produced ocular vestibular evoked myogenic potentials (oVEMPs) in children that were superior to those recorded with the infraorbital-chin electrode derivation. Method This was a prospective observational study using a sample of convenience at a tertiary care medical center. Subjects were 13 children between the ages of 5 and 12 years. We compared the latency of the N1 wave and the N1-P1 peak-to-peak amplitude for the belly-tendon electrode derivation to the infraorbital-chin electrode derivation. Results The belly-tendon electrode derivation was associated with superior N1-P1 amplitudes compared to the infraorbital-chin electrode derivation. However, the large amplitude was also associated with greater variability compared to the infraorbital-chin derivation. There were no significant electrode derivation-based differences in N1 latency. Additionally, there was no predictable relationship between age and oVEMP amplitude. Conclusion As shown previously in adults, the belly-tendon electrode derivation produces significantly larger oVEMP amplitudes compared to the infraorbital-chin electrode derivation.

Evaluation of pediatric glioma outcomes using intraoperative MRI: a multicenter cohort study.

BACKGROUND: The use of intraoperative MRI (iMRI) during treatment of gliomas may increase extent of resection (EOR), decrease need for early reoperation, and increase progression-free and overall survival, but has not been fully validated, particularly in the pediatric population. OBJECTIVE: To assess the accuracy of iMRI to identify residual tumor in pediatric patients with glioma and determine the effect of iMRI on decisions for resection, complication rates, and other outcomes. METHODS: We retrospectively analyzed a multicenter database of pediatric patients (age ≤ 18 years) who underwent resection of pathologically confirmed gliomas. RESULTS: We identified 314 patients (mean age 9.7 ± 4.6 years) with mean follow-up of 48.3 ± 33.6 months (range 0.03-182.07 months) who underwent surgery with iMRI. There were 201 (64.0%) WHO grade I tumors, 57 (18.2%) grade II, 24 (7.6%) grade III, 9 (2.9%) grade IV, and 23 (7.3%) not classified. Among 280 patients who underwent resection using iMRI, 131 (46.8%) had some residual tumor and underwent additional resection after the first iMRI. Of the 33 tissue specimens sent for pathological analysis after iMRI, 29 (87.9%) showed positive tumor pathology. Gross total resection was identified in 156 patients (55.7%), but this was limited by 69 (24.6%) patients with unknown EOR. CONCLUSIONS: Analysis of the largest multicenter database of pediatric gliomas resected using iMRI demonstrated additional tumor resection in a substantial portion of cases. However, determining the impact of iMRI on EOR and outcomes remains challenging because iMRI use varies among providers nationally. Continued refinement of iMRI techniques for use in pediatric patients with glioma may improve outcomes.

Development and Preliminary Findings of the Dizziness Symptom Profile.

OBJECTIVES: Dizziness, vertigo, and unsteadiness are common complaints of patients who present to primary care providers. These patients often are referred to otology for assessment and management. Unfortunately, there are a small number of specialists to manage these patients. However, there are several dizziness disorders that can be successfully managed by primary care providers if the disorder is properly identified. To assist in the identification of several of the most common dizziness disorders, we developed the dizziness symptom profile (DSP). The DSP is a self-report questionnaire designed to generate one or more differential diagnoses that can be combined with the patient's case history and physical examination. DESIGN: This report describes three investigations. Investigations 1 and 2 (i.e., exploratory and confirmatory investigations, N = 514) describe the development of the DSP. Investigation 3 (N = 195) is a validation study that describes the level of agreement between the DSP completed by the patient, and, the differential diagnosis of the otologist. RESULTS: The final version of the DSP consists of 31 items. Preliminary findings suggest that the DSP is in agreement with the differential diagnoses of ear specialists for Meniere's disease (100% agreement), vestibular migraine (95% agreement), and benign paroxysmal positional vertigo (82% agreement). CONCLUSIONS: Early results suggest that DSP may be useful in the creation of differential diagnoses for dizzy patients that can be evaluated and managed locally. This has the potential to reduce the burden on primary care providers and reduce delays in the diagnosis of common dizziness and vertigo disorders.

Anterior Canal benign paroxysmal positional Vertigo following surgical Management of superior canal dehiscence.

OBJECTIVE: Benign paroxysmal positional vertigo (BPPV) is a common post-surgical finding in patients managed for superior semicircular canal dehiscence (SSCD). The posterior semicircular canal has been reported as the involved canal in the majority of cases of post-surgical BPPV, with only two cases reported of lateral canal involvement. The objective of this report is to present a case in which an anterior semicircular canal BPPV response was identified in a patient following surgical management for SSCD. METHOD: This case report presents an adult with residual dizziness following surgical management of SSCD and vestibular rehabilitation therapy (VRT). During subsequent evaluation of vestibular function, a transient and torsional, down-beating nystagmus was provoked along with vertigo during Dix-Hallpike positioning to the right. This was consistent with BPPV affecting the left superior (anterior) semicircular canal. RESULTS: The patient was treated with a repositioning maneuver to manage anterior semicircular canal BPPV and no nystagmus response was recorded with post-repositioning Dix-Hallpike test. Review of radiographic images, obtained prior to vestibular function testing, showed a hyperintensity in the area of the left anterior semicircular canal ampulla. It was felt this was likely a bone chip from the SSCD repair that was pushing against the ampulla with further mobile debris within the canal. CONCLUSION: It is reported that BPPV is a common complication in patients surgically managed for SSCD. Posterior semicircular canal BPPV is reported most often, with a couple of cases of lateral semicircular canal BPPV also reported. As far as we are aware, the current case represents the first report of anterior semicircular canal BPPV in this type of patient.

Ocular and Cervical Vestibular Evoked Myogenic Potentials in Patients With Vestibular Migraine.

OBJECTIVE: To evaluate the relationship between normal and abnormal ocular vestibular evoked myogenic potentials (oVEMP) and cervical vestibular evoked myogenic potentials (cVEMP) in patients with and without vestibular migraine (VM). STUDY DESIGN: Retrospective review of oVEMP and cVEMP results in patients with vestibular disorders who were assessed clinically and completed vestibular function studies. Data were extracted from a deidentified RedCap Repository. SETTING: Tertiary care multispecialty medical center. PATIENTS: Subjects were 212 consecutive adults meeting prespecified inclusion criteria who were evaluated in the Balance Disorders Clinic at Vanderbilt University Medical Center between 2011 and 2017. Patients with bilaterally absent VEMPs were excluded from the study. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Proportions of subjects with or without VM in one of the following four test outcomes: normal cVEMP/normal oVEMP, abnormal cVEMP/abnormal oVEMP, abnormal cVEMP/normal oVEMP, and normal cVEMP/abnormal oVEMP. RESULTS: There was a significant relationship between VM and cVEMP and oVEMP test outcomes. CONCLUSION: Patients with VM are more likely than subjects with vestibular disorders other than migraine to exhibit normal cVEMP responses in the presence of unilaterally abnormal oVEMP responses. Such a VEMP pattern may be a biomarker of VM and further supports a possible pathophysiologic relationship between the utriculo-ocular reflex and VM.

Management of Recurrent Vestibular Neuritis in a Patient Treated for Rheumatoid Arthritis.

PURPOSE: This clinical report is presented to describe how results of vestibular function testing were considered along with other medical history to develop a management plan that was ultimately successful. METHOD: The patient underwent audio-vestibular assessment including comprehensive audiogram, videonystagmography, cervical vestibular evoked myogenic potential, and postural stability testing. RESULTS: Results from initial testing were most consistent with uncompensated peripheral vestibular dysfunction affecting the right superior vestibular nerve. These results, considered along with history and symptoms, supported vestibular neuritis. After a second vertigo event, we became concerned about the potential temporal association between the patient's rheumatoid arthritis treatment and symptom onset. It is established that treatment for rheumatoid arthritis can exacerbate latent viral issues, but this has not specifically been reported for vestibular neuritis. There are reports in the literature in which patients successfully used viral suppressant medication to decrease viral activity while they were able to continue benefiting from immunosuppressive therapy. We hypothesized that, if the current patient's vestibular neuritis events were related to her treatment for rheumatoid arthritis, she may also benefit from use of viral suppressant medication while continuing her otherwise successful immunosuppressive intervention. CONCLUSIONS: Patients treated with biologic disease-modifying antirheumatic drugs are more susceptible to viral issues, and this may include vestibular neuritis. For the current case, identifying this possibility and recommending viral suppressant medication allowed her to continue with successful treatment of rheumatoid arthritis while avoiding additional vertigo events.

Teaching Patient-Centered Counseling Skills for Assessment, Diagnosis, and Management of Benign Paroxysmal Positional Vertigo.

Audiologists are an integral part of the management of those with dizziness and vestibular disorders. However, little research has been performed on counseling approaches for patients who present with dizziness as a primary concern. Accordingly, it is important that audiology students are provided with didactic and experiential learning opportunities for the assessment, diagnosis, and management of this population. Benign paroxysmal positional vertigo is the most common vestibular disorder among adults. Doctor of Audiology students, at a minimum, should be provided with learning opportunities for counseling patients with this particular disorder. Implementation of patient-centered counseling is applied across various parts of the patient encounter from initial intake to treatment and patient education. The purpose of this article is to present the available evidence and to apply widely accepted theories and techniques to counseling those with benign paroxysmal positional vertigo. Didactic resources and experiential learning activities are provided for use in coursework or as a supplement to clinical education.

Correction of metopic synostosis utilizing an in situ bandeau approach.

Metopic craniosynostosis is a common growth disturbance in the infant cranium, second only to sagittal synostosis. Presenting symptoms are usually of a clinical nature and are defined by an angular forehead, retruded lateral brow, bitemporal narrowing, and a broad-based occiput. These changes create the pathognomonic trigonocephalic cranial shape. Aesthetic in nature, these morphological changes do not constitute the only developmental issues faced by children who present with this malady. Recent studies and anecdotal evidence have also demonstrated that children who present with metopic synostosis may face issues with respect to intellectual and/or psychological development. The authors present an elegant approach to the surgical reconstruction of the trigonocephalic cranium using an in situ bandeau approach.

An adaptive clinical test of temporal resolution: within-channel and across-channel gap detection.

OBJECTIVE: Several methods exist to measure temporal resolution in a clinical setting. The Adaptive Tests of Temporal Resolution (ATTR©) are unique in that they incorporate an adaptive psychophysical procedure to present stimuli via computer sound card. The purpose of this study was to determine if ATTR gap detection thresholds (GDTs) were stable across presentation levels (80 dB SPL, listener-selected level) and sound cards (high-end, inexpensive). DESIGN: GDTs were measured using three conditions of the ATTR: broad-band noise within-channel (BBN-WC), narrowband noise within-channel (NBN-WC), and narrowband noise across-channel (NBN-AC). Analysis of the acoustical properties of ATTR stimuli was made by measuring the electrical signals produced by each sound card. STUDY SAMPLE: Participants were 30 young adults with normal hearing. RESULTS: The ATTR GDTs did not differ between presentation levels for all three stimulus conditions. Also, neither ATTR stimuli nor ATTR GDTs differed between sound cards for all conditions. CONCLUSIONS: The ATTR may be used in a clinical setting with a relatively inexpensive sound card and listener-selected levels. Normative performance values for each ATTR condition are provided.