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DOI: 10.1177/0194599812452993

2012 147: 912 originally published online 29 June 2012Otolaryngology -- Head and Neck SurgeryMei-Chun Lin and Yi-Ho Young

The Use of Vestibular Test Battery to Identify the Stages of Delayed Endolymphatic Hydrops

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Original ResearchOtology and Neurotology

The Use of Vestibular Test Battery toIdentify the Stages of DelayedEndolymphatic Hydrops

Otolaryngology

Head and Neck Surgery

147(5) 912918

American Academy of

OtolaryngologyHead and Neck

Surgery Foundation 2012

Reprints and permission:

sagepub.com/journalsPermissions.nav

DOI: 10.1177/0194599812452993

http://otojournal.org

Mei-Chun Lin, MD1, and Yi-Ho Young, MD1

No sponsorships or competing interests have been disclosed for this article.

Abstract

Objective. Patients with delayed endolymphatic hydrops (DEH)underwent a vestibular test battery to evaluate the residualfunction, assess their clinical stage, and predict outcome.

Study Design. Case series with chart review.

Setting. University hospital.

Subjects and Methods. Twenty patients with DEH, 15 with

ipsilateral type and 5 with contralateral type, were enrolled.All patients underwent audiometry and caloric, ocularvestibular-evoked myogenic potential (oVEMP), and cervicalVEMP (cVEMP) tests. The DEH staging was based on vestib-ular test results. Stage 0 indicates that all 3 vestibular testsare normal, while stages I through III indicate abnormalresults in tests 1 through 3, respectively.

Results. Of the 20 DEH patients, 2 patients were stage 0, 12patients were stage I, 4 patients were stage II, and 2 patientswere stage III. The median frequency of vertigo in patientswith stages II and III was 4 episodes monthly, significantlyless than 15 episodes monthly in those with stages 0 and I.

Ipsilateral and contralateral types did not differ significantlyin the stage distribution. The percentages of abnormalcVEMP, oVEMP, and caloric test results for patients with ipsi-lateral type were 80%, 33%, and 13%, not significantly differ-

ent from those for contralateral type.

Conclusions. As a vertiginous attack may subside sponta-neously for patients with long-term DEH, one must identify

its clinical stage based on cVEMP, oVEMP, and caloric testresults. In early stage DEH, most vestibular function

remained relatively intact, leading to repeated vertiginousattacks. Conversely, subsidence of vertiginous episode canbe anticipated in patients with late stage DEH.

Keywords

delayed endolymphatic hydrops (DEH), vestibular-evokedmyogenic potential (VEMP), cervical VEMP (cVEMP), ocular

VEMP (oVEMP)

Received March 23, 2012; revised May 14, 2012; accepted June 6, 2012.

Ipsilateral delayed endolymphatic hydrops (DEH) refers

to one ear with profound hearing loss. After several

years or decades, episodic vertigo occurs, accompanied

by nausea and vomiting.1,2 Contralateral DEH exhibits the

same features as ipsilateral DEH and hearing loss in the

opposite (better) ear fluctuates. Via a long-term follow-up

study of cases with both ipsilateral and contralateral DEH,

Kamie3 reported that 65% to 90% of cases had episodic ver-

tigo that vanished within 5 to 10 years.

According to the American Academy of Otolaryngology

Head and Neck Surgery,4 Menieres disease staging was based

on the arithmetic mean of pure tone thresholds at 0.5, 1, 2,

and 3 kHz using the worst audiogram at 6 months before treat-

ment. However, this staging system for Menieres disease

cannot be applied to cases with ipsilateral DEH, since the

latter manifests as profound sensorineural hearing loss on the

lesion ear. Alternatively, the interaural amplitude difference

(IAD) ratio (now termed asymmetry ratio) of the vestibular-

evoked myogenic potential (VEMP) test correlates with

Menieres disease stage and can be used as another tool forassessing the stage of Menieres disease.5

By stimulating the ear with loud sound or bone vibration

stimuli, VEMP can be recorded on contracted neck muscles,

now called cervical VEMP (cVEMP), and on the extraocular

muscles, termed ocular VEMP (oVEMP).6-8 These two

recently developed electrophysiological tests expand the test

battery for clinicians to assess utricular and saccular hydrops

in patients with Menieres disease.9-11 Based on the hypothesis

of efferent specificity proposed by Curthoys,12 cVEMP

arises from the saccular macula, whereas oVEMP predomi-

nantly originates from the utricular macula. Thus, when using

the inner ear monitoring system13

such as audiometry andcVEMP, oVEMP, and caloric tests to study the localization

and prevalence of hydrops formation, it reveals that the declin-

ing function in the cochlea, saccule, utricle, and semicircular

canals mimics the declining sequence of hydrops formation in

temporal bone studies.14,15 As the disease progresses, canal

1Department of Otolaryngology, National Taiwan University Hospital,

Taipei, Taiwan

Corresponding Author:

Yi-Ho Young, MD, Department of Otolaryngology, National Taiwan

University Hospital, 1 Chang-te St, Taipei, TaiwanEmail: [email protected]

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paresis is noted in 50% of Menieres patients after the first

decade.16,17 Restated, the fluctuation of endolymphatic hydrops

can be reflected by functional deterioration and recovery of

the cochlea, saccule, utricle, and semicircular canals. Thus, in

this study, DEH patients underwent a vestibular test battery to

evaluate residual vestibular function, assess their clinical stage,

and predict outcome.

Patients and Methods

Patients

From January 2009 to December 2010, consecutive 20

patients with DEH were encountered at the clinic (less than

180 patients with Menieres disease experienced during the

same period). The diagnosis of DEH was based on the liter-

ature.18 Briefly, one ear suffered from profound hearing loss

previously, with a pure tone average of 500, 1000, and 2000

Hz . 90 dB. Following several years or decades, episodic

vertigo accompanied by nausea/vomiting occurs (ipsilateral

type), or fluctuating hearing loss is noted on the opposite

ear (contralateral type). No central nervous system disorderwas observed.

Exclusion criteria consisted of concurrent middle or inner

ear infection or anomaly, previous ear surgery, systemic dis-

eases, neurological diseases (eg, acoustic neuroma and brain

tumor), and recent head trauma (within 6 months).

Eight patients were men and 12 patients were women,

with their ages ranging from 25 to 68 years (mean, 48 years).

Right side was affected in 7 ears and left side in 13 ears.

Fifteen patients were classified as ipsilateral type, while 5

patients belonged to contralateral type (Table 1). Neither

temporal bone CT scan nor MR imaging revealed abnormal-

ities in these patients. Prior to treatment, all patients underquiescent state received a battery of tests including otoscopy,

audiometry, and caloric, oVEMP, and cVEMP tests.

This study was approved by the institutional review

board of the College of Medicine, National Taiwan

University Hospital, and each subject signed the informed

consent to participate.

Caloric Test

Bithermal caloric test was conducted with electronystagmo-

graphic recorders (Sanei 1B21, Tokyo, Japan). Canal paresis

was defined when the mean slow phase velocity (SPV)\ 17o/s,

or as a greater than 25% difference between maximum slowphase velocity measurements for each ear, when compared with

the sum of SPVs from each ear. If no caloric response was eli-

cited, the subject underwent ice water (0oC, 10mL) caloric test-

ing to further confirm the caloric areflexia.

oVEMP Test

The subject was in a sitting position. Surface potentials, pre-

dominantly electromyographic (EMG) activities, were

recorded (Smart EP 3.90, Intelligent Hearing Systems,

Miami, Florida, USA). Two active electrodes were placed

around 1 cm below the center of the 2 lower eyelids. The

other 2 reference electrodes were positioned about 1 to 2

cm below the active ones, and 1 ground electrode was

placed on the sternum. During recording, the subject was

instructed to look upward at a small fixed target . 2 m

from the eyes, with a vertical visual angle of approximately

30o above horizontal. The EMG signals were amplified and

bandpass filtered between 1 and 1000 Hz. The stimulation

rate was 5 Hz. The duration of analysis of each response

was 50 ms, and 30 responses were averaged for each run.

The operator held the vibrator by hand so that the axis ofthe connected bakelite cap perpendicularly delivered a

repeatable tap on the subjects skull at Fz (midline of the

hairline). The initial peak driving voltage was about 8 V,

equivalent to 128 dB force level (FL). The input signal was

a half cycle 500 Hz sine wave, driven by a custom

amplifier.

The initial negative-positive biphasic waveform com-

prised peaks nI and pI. Consecutive runs were performed to

confirm the reproducibility of peaks nI and pI, and oVEMPs

were deemed to be present. Conversely, oVEMPs were

deemed to be absent when the biphasic waveform was not

reproducible. At our laboratory, the norm for the latency ofpeak nI was 11.4 6 0.8 (mean 6 SD) ms. Those with the nI

latency exceeding 13.0 ms were defined as delayed

response. The asymmetry ratio (%) was defined as the dif-

ference of the amplitude nI pI on each ear divided by the

sum of amplitude nI pI of both ears, that is, (larger ampli-

tude smaller amplitude / larger amplitude 1 smaller

amplitude) 3 100. Those with asymmetry ratio . 40%

were interpreted as reduced responses.19

cVEMP Test

Each subject was in a supine position. Two active electrodes

were placed on the upper half of the sternocleidomastoid(SCM) muscles; one reference electrode was positioned on

the suprasternal notch, and a ground electrode was situated

on the forehead. The other settings were the same as in the

oVEMP test, except that the vibrator delivered a repeatable

tap on the subjects head at inion.19 To measure background

muscle activity, subjects were given feedback of the level

of EMG activity in their SCM muscles during data collec-

tion and were required to keep a background muscle activity

of at least . 50 mV.20 The subjects elevated their heads

during testing. A total of 50 responses were averaged and

recorded bilaterally.

The first positive and second negative polarities of bipha-sic waveform were termed waves p13 and n23, respectively.

Consecutive runs were performed to confirm the reproduci-

bility of peaks p13 and n23, and cVEMP responses were

termed present. The latencies of p13, n23, and amplitude

p13 n23 were measured. At our laboratory, the norm for

the latency of p13 was 14.4 6 1.3 (mean 6 SD) ms, and

we defined when the latency of peak p13 exceeding 17.0 ms

as delayed cVEMPs. In addition, those with asymmetry

ratio . 33% were defined as reduced response.

Statistical Methods

Comparison of the abnormal test results between the 2 types

was analyzed by Fishers exact test. Comparison of the

Lin and Young 913



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abnormal test results between the 2 sides was analyzed by

McNemar test. Frequency of vertigo between the stages was

compared by Mann-Whitney U test. A significant difference

indicates the P value\ .05.

Results

Clinical Manifestation

Clinical manifestation consisted of hearing loss in all 20

patients, vertigo in 15 (75%), nausea in 13 (65%), tinnitus

in 11 (55%), headache in 8 (40%), and aural fullness in 7

(35%). The median interval between initial deafness and

diagnosis of DEH was 10 years (range, 2-30 years).

Audiometry

All patients had profound hearing loss (. 90 dB) in at leastone ear. For the better hearing ear, the 4-tone average at

0.5, 1.0, 2.0, and 3.0 kHz was\ 26 dB in 12 ears, 26 to 40

dB in 5 ears, and 41 to 70 dB in 3 ears ( Table 1).

Vestibular Test Battery

Of the 20 affected ears (Table 2), the cVEMP test identi-

fied normal responses for 6 ears and abnormal responses for

14 ears (70%), including absent cVEMPs in 13 ears and

delayed cVEMPs in 1 ear. The oVEMP test revealed normal

responses for 11 ears and abnormal responses for 9 ears

(45%), consisting of absent oVEMPs in 8 and reduced

oVEMPs in 1. With the caloric test, normal responses were

shown in 17 ears and canal paresis was observed in 3 ears

(15%).

For the opposite unaffected ears, the cVEMP, oVEMP,

and caloric tests identified abnormal responses in 55%,30%, and 30% of the ears, respectively (Table 2). There

were no significant differences in the abnormal percentage

of the 3 tests between the affected and unaffected ears (P .

.05, McNemar test).

DEH Staging

The DEH staging was based on cVEMP, oVEMP, and calo-

ric test results. Stage 0 indicates that all 3 test results of the

affected ear are normal; stage I indicates that 1 of 3 test

results are abnormal (Figure 1); stage II indicates that 2

test results are abnormal (Figure 2); and stage III indicates

that no test result is normal. Of the 20 DEH patients, 2patients were classified as stage 0, 12 patients were stage I,

4 patients were stage II, and 2 patients were stage III

(Table 2).

Frequency of Vertigo versus DEH Stage

Frequency of vertigo is defined as the total vertiginous epi-

sodes within 1 month before treatment. Of the 15 DEH

patients with vertigo, the median frequency of vertigo for

patients with stages II and III was 6 episodes (range, 1-10)

monthly, significantly less than 15 episodes (range, 6-30)

monthly in those with stages 0 and I (P \ .05, Mann-

Whitney U test).

Table 1. Clinical Information of 20 Patients with Delayed Endolymphatic Hydrops

Four-Tone Average(dB)

Case No. Age, y Sex Side Type Right Left

1 68 F R I so 28

2 68 M R I so 38

3 57 F R I so 194 42 F R I so 26

5 25 F R I 93 12

6 61 M R I so 28

7 45 M R I so 13

8 57 F L I 24 so

9 42 F L I 4 so

10 52 F L I 18 so

11 34 M L I 11 94

12 58 M L I 36 so

13 68 F L I 23 90

14 48 F L I 6 so

15 32 F L I 12 so16 34 M L C so 53

17 55 F L C so 64

18 40 F L C so 19

19 29 M L C 103 51

20 55 M L C so 17

Abbreviations: I, ipsilateral type; C, contralateral type; so, scale out.

914 OtolaryngologyHead and Neck Surgery 147(5)



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Ipsilateral versus Contralateral Types

The percentages of abnormal cVEMP, oVEMP, and calorictest results were 80%, 33%, and 13% for ipsilateral type

and 40%, 80%, and 20% for contralateral type, respectively.

Both types did not differ significantly, regardless of whether

cVEMP, oVEMP, or caloric test results were analyzed (P .

.05, Fishers exact test). One, 10, 3, and 1 patients of ipsilat-

eral type and 1, 2, 1, and 1 patients of contralateral type

were classified as having stage 0, I, II, and III, respectively.

The staging distribution did not significantly differ for both

types (P . .05).

Discussion

The mechanism of DEH is a sufficiently major labyrinthineinsult that causes total deafness while vestibular function is

preserved, producing delayed atrophy or fibrous obliteration

of the endolymph resorption system.2 Thus, clinical expres-

sions of DEH vary with involvement severity. The most

severe involvement results in immediate total loss of auditory

and vestibular function, whereas the mildest involvement

causes delayed malfunction of endolymph resorption, result-

ing in episodic vertigo (ie, ipsilateral type) and/or fluctuating

hearing loss (ie, contralateral type). Clinically, it is usually

difficult to determine the ear causing vertigo when ipsilateral

DEH occurs in patients with bilateral profound hearing loss

unless it is accompanied by tinnitus or aural fullness during

episodic vertigo. When the vestibular involvement occurs in

both ears, termed bilateral DEH, the time of onset could be

different for each ear. In other words, 2 situations are sup-

posed in bilateral DEH; namely, both ears are affected by the

ipsilateral type, or 1 ear is affected by the ipsilateral type

while the other ear is affected by the contralateral type.3

Nevertheless, such a case has rarely been observed.

As the recently developed inner ear test battery including

audiometry and cVEMP, oVEMP, and caloric tests investi-

gates the inner ear function completely,13 it may assist clini-

cians in evaluating inner ear involvements in DEH patients

with various inner ear insults.

Inner Ear Test Battery

The presence of normal cVEMPs implies that the sacculo-collic reflex has retained normal conduction velocity; an

intact saccular macula accounts for normal cVEMPs.

Histopathological study of DEH demonstrated that the sac-

cule was markedly dilated with the saccular macula either

severe degenerated or apparently normal, accompanied by

partial cellular encapsulation of the otolithic membrane, and

a granular basophilic plaque overlying the supporting net-

work of the macular epithelium.2 These findings correlate

with the high rate (70%) of abnormal cVEMPs for DEH

patients (Table 2) and are compatible with those in previ-

ous reports.21,22

However, DEH ears with absent cVEMPs also provoke

episodic vertigo, indicating that factors other than saccule

Table 2. Vestibular Test Results in 20 Patients with Delayed Endolymphatic Hydrops

Case No.

(ears)

cVEMP Test

(affected/opposite)

oVEMP Test

(affected/opposite)

Caloric Test

(affected/opposite) Stage

1 absent/absent n/absent n/n I

2 absent/n n/absent cp/n II

3 absent/n n/n n/n I



6 absent/n absent/absent cp/absent III

7 absent/absent n/n n/n I

8 n/n absent/n n/n I

9 n/n n/n n/n 0

10 absent/delayed n/n n/n I

11 n/absent reduced/n n/n I

12 delayed/absent absent/n n/n II

13 absent/n absent/n n/n II



16 n/n absent/n n/absent I

17 absent/absent absent/absent cp/absent III

18 absent/absent absent/absent n/absent II

19 n/absent absent/absent n/absent I

20 n/absent n/n n/cp 0

Abnormal rate 70%/55%a 45%/30%a 15%/30%a

Abbreviations: cp, canal paresis; n, normal.aP. .05, McNemar test.

Lin and Young 915



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Figure 1. Case No. 5, female, 25 years, delayed endolymphatic hydrops, right, stage I, ipsilateral type. Caloric test results are normal. The

oVEMP test shows normal (nI pI) responses, bilaterally. The cVEMP test shows absent responses on the right ear, but normal (p13 n23)

responses on the left ear.

Figure 2. Case No. 13, female, 68 years, delayed endolymphatic hydrops, left, stage II, ipsilateral type. Caloric test results are normal. Both

oVEMP and cVEMP tests show normal responses on the right ear, but absent responses on the left ear.




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prevail. Thus, function of the utricle and semicircular canals

warrants further investigation.

As it stimulates the semicircular canals, the caloric test

has been utilized to analyze the rotational vestibulo-ocular

reflex (VOR) system in individual ears for over 100 years.

In contrast, the recently developed oVEMP test assesses the

translational VOR by activating the otolithic maculae. As

saccular neurons have a strong projection to neck musclesand a weak projection to the oculomotor system, neural con-

nections in the sacculo-ocular system are relatively weak

compared with neural connections in the utriculo-ocular and

sacculo-collic reflexes.23 Thus, the oVEMP test may reflect

utricular macula activity. Unlike the substantial damage to

the pars inferior (cochlea and saccule) in DEH patients, the

pars superior (utricle and canals) was relatively intact, as

evidenced in a temporal bone study by the normal appear-

ance of the utricular macula, crista ampullaris, and semicir-

cular ducts except for dilatation of the utricle.2 These

findings may explain why abnormal percentages of oVEMP

(45%) and caloric (15%) tests are less than that of thecVEMP (70%) test. Even in the opposite unaffected ears,

similar deteriorated results are also observed (Table 2),

indicating that primary labyrinthine insult may cause poten-

tial defects in both ears. Once both ears showed deteriorated

functions in vestibular test battery, which ear having tinnitus

or aural fullness during vertiginous episode was considered

to be the cause of vertigo.

In our previous report,14 abnormal percentages of cVEMP,

oVEMP, and caloric tests in Menieres ears were 45%, 25%,

and 20%, respectively. In this study, those in DEH cases

were 70%, 45%, and 15%, respectively. Notably, the declin-

ing sequence of abnormal percentages of cVEMP, oVEMP,and caloric tests in DEH cases mimics that in Menieres

cases, and this further supports that DEH and Menieres dis-

ease may, at least in part, share the same pathophysiology.

In late stage Menieres disease, severe dilatation or col-

lapsed ampullary walls may interfere with cupular move-

ment, resulting in a poor caloric response.17 The vestibular

sense organs may also undergo severe atrophic change.

After repeated ruptures of the labyrinthine membrane, par-

tial or total collapse of the membranous labyrinth ensues.

This condition is coined as vestibular atelectasis.24 These

histopathological findings explain why caloric areflexia was

observed in late stage Menieres disease, leading to sponta-neous relief of vertigo. As only 15% of DEH ears in this

study showed canal paresis, one may expect that most

patients had preserved canal function, leading to frequent

vertiginous attacks. Conversely, most vestibular function

deteriorates in late stage DEH patients, which may cause

relief of vertiginous episode. Hence, investigating residual

vestibular function to identify the clinical stage of DEH is

necessary.

However, one may question whether a physician can

base the decision on whether someone is at a late stage of

DEH according to the number of episodes of vertigo he or

she has. As some DEH patients with episodic vertigo may

visit other hospitals for help, the true numbers of episodic

vertigo may be higher than estimation. Nevertheless, this dis-

advantage can be overcome with the aid of caloric, oVEMP,

and cVEMP tests, which may help evaluate the residual ves-

tibular function in deaf ears. It takes a short time (approxi-

mately 20 minutes) for both oVEMP and cVEMP tests, and

the fee for the vestibular test battery (including ENG,

oVEMP test, and cVEMP test) at our hospital costs US$70,

which is significantly less than a routine MR imaging(US$700). Thus, it would be practical to make the inner ear

test battery a routine examination in DEH patients.

Clinical Relevance

As episodic vertigo disappeared in 90% of DEH patients

within 10 years,3 vertiginous attacks may subside sponta-

neously. For those with intractable vertigo, surgical labyr-

inthectomy or intratympanic gentamicin injections may be

an alternative treatment for abolition of the vestibular func-

tion.18 Our study is useful because when a surgeon can

identify the DEH stage, surgical intervention may be

reserved in late stage DEH patients. For patients with pro-found deafness and recalcitrant vertigo, surgical labyr-

inthectomy or gentamicin injection should be mentioned as

a treatment option, and this may be reasonable early in the

disease process since many DEH patients ultimately lose

significant vestibular function.

Conclusion

As a vertiginous attack may subside spontaneously for

patients with long-term DEH, one must identify its clinical

stage based on cVEMP, oVEMP, and caloric test results. In

early stage DEH, most vestibular function remained rela-

tively intact, leading to repeated vertiginous attacks.Conversely, subsidence of vertiginous episode can be antici-

pated in patients with late stage DEH, and surgical interven-

tion may be set aside.

Author Contributions

Mei-Chun Lin, performed VEMP and wrote paper; Yi-Ho Young,

supervised study.

Disclosures

Competing interests: None.

Sponsorships: None.

Funding source: None.

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