Genyk: Assessment of Vestibular Function in Case of Labyrinthopathy



Problem statement and analysis of the recent research

Dizziness and vertigo occurs in more then 20% of Global population, 36% of females and 29% of males complaining are consulted by physicians, it has a prevalence of 22.9-39% [4, 11, 32]. Dizziness means space, movement and time perceptual disorder [2, 10]. There are several types of vertigo: objective vertigo is a sensation of the subjects moving around the patient, subjective vertigo is an illusion of nonexistent movement [24], pseudovertigo is vertigo which is not similar to subjective or objective ones; it is very intensive, difficult to describe, patients often complaint that something (for example, brain) moves inside of the head [22, 26]. Compared to dizziness, vertigo is more frequently followed by medical consultation (70% vs. 54%; p<0.001), disablement (41% vs. 15%; p<0.001), disorder of activities of daily living (40% vs. 12%; p<0.001), and avoidance of leaving the house (19% vs. 10%; p=0.001) [14, 19, 27]. In many cases dizziness has functional character. Only in 29% the CT scans and in 40% MRI have shown abnormalities: atrophies, infarctions, demyeliniation [20]. Generally, being widely spread, dizziness is insufficiently studied, often resistant to therapy and results in patient’s disablement [31]. Large-scale study of dizziness has been performed since 1974 by Neurootological and Equilibriometric Society (Germany). Together with Bárány Society (Sweden) and Society for Neuroscience (USA) they have developed the concept of vestibular system, which involves the vestibular peripheral sensors, tetrad of space orientation, vestibular parts of the brain cortex and vestibular effectory projections in the brain [26, 27].

Vestibule consists of at least two systems: great type I hair cells, contacting with thick fibers and forming direct 3 neuron pathway to contralateral cortex and small type II hair cells innervated with thin fibers forming polysynaptic pathway. First system disorder leads to vertigo, second system disorder leads to dizziness. Vertigo is considered to be typical for cupulolithiasis, vestibular neuronitis (neuritis), Ménière’s disease and syndrome [24]. Dizziness is more typical for intoxications and chronic diseases. In the cases of vertigo, calcium and Н1 histaminic receptor blockers are effective. Nootropic drugs are more effective in case of dizziness [6, 8, 27].

Ménière’s disease and syndrome are diagnosed because of sudden onset and typical triad: vertigo (often with vomiting and loss of balance), tinnitus and diminished hearing. Diuretics cause quick relief in the case of true Ménière’s disease, they appear to be beneficial both from the diagnostical and symptomatic treatment positions. They seem to be ineffective in the cases of Ménière’s syndrome [1].

The prevalence of Ménière’s disease is reported to be between 43 and 218.2 cases/100000; incidence is 4.3-45/100000 population [12, 33]. In the Framingham study, (Framingham, Mass, USA) 1.48 % of the population claimed to have a history of Ménière’s disease [18]. Principal factor in the disease formation is considered to be the insufficiency of endolymphatic duct. Decompensation appears as a result of viral or bacterial infection, causing labyrinthine hydrops [17], which in severe cases lead to semitendinous labyrinth ruptures. Acute episodes of disease tend to occur in clusters with a mean frequency of 6-11 clusters per year, though the remission periods may last several months [16]. Diagnostic Guidelines (AAO-HNS, 1995) [3]: 1) at least two spontaneous episodes of severe rotational vertigo lasting minimum 20 minutes; 2) audiometric confirmation of sensorineural hearing impairment; 3) tinnitus and/or perception of aural fullness. For final diagnosis clinical picture, vestibular and auditory evoked potentials, as well as caloric test are also evaluated [7, 26, 27].

In addition to Ménière’s disease there are certain clinical forms, related to Ménière’s triad. Labyrinthine fistula is developing next to lateral semicircular canal as long-term consequence of cholesteatome. It may be suspected with constant puruleous otorhea, positive Tulio phenomenon (nystagmus when pressing the tragus) [30]. CT gives the chance to establish final diagnosis [23]. Serous labyrinthitis is characterized by expressed vertigo, tinnitus and hearing loss, accompanied with horizontal nystagmus opposite to the affected labyrinth. Caloric test shows canal paresis; cranio-corpo-graphy indicates coordination impairment with clear lateralization, MRI might show changes in the structure of pyramid [15, 27]. In some cases Ménière’s triad may be associated with chronic otitis, otosclerosis, head trauma, herpes group viruses, syphilis, hyperinsulinemia, hypothyroidism, Cogan’s syndrome, Mondini dysplasia and psychotrauma [13].

The main research methods of vestibular-spinal reactions are Romberg’s [21], Fukuda’s and Uemura’s [9] tests, sensitivity of which reached 98.15% for certain groups of patients [25], and Uemura’s test can be used as an express-test for vestibular function evaluation [29], but it is not informative alone in the cases of low extremities diseases. Therefore, 20-point rating scale has been proposed for express-diagnostics of coordination function [26-28], which includes complaints quantification, Uemura’s test, writing and stepping tests, tracking and past-pointing test.

The objectiveThe objective of the research was to assess the degree of vestibule damage in patients with labyrinth dysfunction (labyrinthopathy) using a 20-point rating scale for express-diagnostics of motion coordination.

Materials and methods of the research

The study involved 25 patients with labyrintopathy of otogenic origin, the median age of them was 41 (38; 44) year. They included 17 women (68%) at the age of 42 (38; 44) and 8 men (32%) at the age of 41 (38; 44.5). All patients had classic Meniere’s triad: vertigo, tinnitus and diminished hearing. An examination of all patients detected horizontal nystagmus. All patients underwent a 20-point rating scale for express-diagnostics of coordination function.

Complaints quantification. Dizziness attacks were considered to be significant when their duration was more than one minute and frequency was more than once per month. Standardized results were described as following:

  • 0 points – complaints are absent;

  • 1 point – complaints of dizziness (or vertigo) with duration over 1 minute;

  • 1 point – complaints of dizziness (or vertigo) with frequency exceeding once per month;

  • 1 point – complaints of accompanying symptoms.

Possible signs combination were expressed in figures from 0 to 3.

Uemura’s test was performed in 4 steps:

  1. Standing at two feet with eyes opened;

  2. Standing at two feet with eyes closed;

  3. Standing at one foot with eyes opened;

  4. Standing at one foot with eyes closed.

Uemura’s test was evaluated in 5 point score:

  • 0 – patient is stable 10 seconds with eyes closed at one foot;

  • 1 – undulating moderately, but keeping balance;

  • 2 – keeping balance using hands (hand is reaching shoulder level);

  • 3 – cannot stand at a spot or stands 3-10 seconds;

  • 4– cannot stand at one foot even 3 seconds;

  • 5 – cannot stand even at two feet.

Lateralization of displacements and falls were important.

Fukuda’s stepping test. On the flour three concentric circles were painted with diameters of 0.5 m, 1 m and 1.5 m. In these circles four perpendicular lines were drawn. Patient was proposed to stand in the very center and align himself with one of the lines. Then he was asked to make 100 steps at spot with eyes closed [5]. Three principal parameters were considered during test performance:

  1. Displacement distance;

  2. Displacement angle;

  3. Spin (rotation) angle.

Forward linear displacement at the distance of 0.2-1.0 m, angle up to 30° and rotation up to 30° were considered normal. Displacement absence or backward displacement, especially with large sway was regarded as disturbance. Test evaluation was proceeded with three score system:

  • 0 – points forward displacement at a distance of 0.2-1.0 m, displacement and spin to the angle up to 30°;

  • 1 – displacement less than 0.2 m or more than 1.0 m;

  • 1 – displacement at the angle more than 30°;

  • 1 – spinning at the angle more than 30°.

Fukuda’s writing test. Patient was proposed to write “33” in column with eyes closed [29]. Standardization of the results looked as following:

  • 0 – column is strait;

  • 1 – column is undulating;

  • 2 – column declines more than 30°;

  • 3 points – dysmetria.

Tracking. Patient was proposed to track small bright subject, moving horizontally and vertically. Quantification of test results was the next:

  • 0 – tracking was smooth in all the eyes positions;

  • 1 – non-smooth in lateral positions;

  • 2 – non-smooth not only in lateral positions;

  • 3 – spontaneous eye movements (nystagmus, saccades).

Past-pointing test. Patient was proposed to point with pen or pencil the target with eyes closed at the distance of stretched hand. Results might be fixed at the sheet of paper. Assessment:

  • 0 – hitting the diameter of 25 mm; 1 – hitting the diameter of 50 mm;

  • 2 – hitting the diameter of 75 mm;

  • 3 – hitting outside the diameter of 75 mm.

Direction of mispointing was fixed separately.

According to the result of all the tests vestibular function was evaluated from 0 to 20 points. Figures from 0 to 4 were characterizing the norm, 5-9 points indicated small degree of vestibular dysfunction, 10-14 – moderate pathology, and 15-20 – severe lesion, mostly organic [25].

Results of the research and their discussion

The most often complaints of patients were dizziness, headache, black-outs, nightmares, tinnitus, memory problems, depressions and consciousness losses, as well as weakness, fatigue, loss of initiative, time perception changes. There were also autonomic disorders, such as nausea, vomiting, diarrhea, sweating, palpitations, which also should be considered according to some authors [2, 29]. The median figure for this scale was 3 (2; 3) points and it was slightly higher for women than for men (3 (2; 3) and 2 (2; 3) points respectively) (Table 1).

Table 1.

Median figures (Me (25%; 75%)) of 20-point rating scale for express-diagnostics of coordination function in patients with labyrinthopathy

Women Men All
Complaints quantification 3 (2; 3) 2 (2; 3) 3 (2; 3)
Uemura’s test 3 (2; 4) 3 (1; 3.5) 3 (2; 4)
Fukuda’s stepping test 2 (1; 3) 2 (1; 2.5) 2 (1; 3)
Fukuda’s writing test 3 (2; 3) 2 (1.5; 3) 2 (2; 3)
Tracking 2 (2; 3) 2 (1.5; 3) 2 (2; 3)
Past-pointing test 2 (2; 2) 2 (1; 2.5) 2 (2; 2)
Total 15 (13; 17) 14 (9; 16) 14 (10; 17)

Assessing Uemura’s test the best performance was taken into account. If the patient was stable at one foot with eyes closed more than 10 seconds, he was considered to be healthy. The median figure for this scale was 3 (2; 4) points and hardly differed in groups of women and men (3 (2; 4) and 3 (1; 3.5) points, respectively) (Table 1). The sensitivity of Uemura’s test appeared to be of 98.90% (n=912) [25, 26] and it can be used as an express-test for vestibular function evaluation [29] at inclusion of the lower extremities disease.

Assessing Fukuda’s stepping test, height and step length of the patient were taken into account. The sensitivity of this test was 82.89% and specificity constituted 99.78% (n = 912) [25, 27]. It was noted that displacement direction in many cases indicated lateralization of the lesion. The median figure for this scale was 2 (1; 3) points and was almost the same for groups of women and men (2 (1; 3) and 2 (1; 2.5) points, respectively) (Table 1).

The median figure when assessing Fukuda’s writing test constituted 2 (2; 3) points and it was slightly higher for women than for men (3 (2; 3) and 2 (1.5; 3) points, respectively) (Table 1).

In the course of tracking assessment, patients were previously interviewed about spending much time at monitors, which might influence the test result. The median figure for this scale was 2 (2; 3) points and was almost the same for groups of women and men (2 (2; 3) and 2 (1.5; 3) points, respectively) (Table 1).

The median figure in past-pointing test assessment was 2 (2; 2) points and was almost the same for groups of women and men (2 (2; 2) and 2 (1; 2.5) points, respectively) (Table 1).

The sensitivity of 20-point test battery for express-diagnostics of coordination function reaches 93.64% (n=912) [25]. Among the examined patients the median figure for this scale was 14 (10; 17) points and for women was slightly higher than for men (15 (13; 17) and 14 (9; 16) points, respectively) (Table 1). This figure corresponds to the moderate severity of vestibular analyzer pathology.

Conclusions

Thus, the moderate severity of labyrinthopathy (20-point test battery for express-diagnostics of coordination function - 14 (10; 17) points) was detected in the majority of examined patients and tendency to more severe disease in female patients was noted. The most significant changes were observed when assessing complaints of patients and Uemura’s test, which probably indicates the highest sensitivity of these tests in patients with labyrinthopathy of otogenic origin.

References

1 

A Burgess, S Kundu. Diuretics for Ménière’s disease or syndrome. In: A Burgess, editor. Cochrane Database of Systematic Reviews . Chichester, UK: John Wiley & Sons, Ltd; 20062006. 10.1002/14651858.CD003599.pub2

2 

CF Claussen. Schwindel, symptomatik, diagnostik, therapie. Hamburg: Edition m+p. Dr. Werner Rudat und Co; 1983.

3 

Committee on Hearing and Equilibrium guidelines for the diagnosis and evaluation of therapy in Meniere’s disease. Otolaryngol - Head Neck Surg. 1995;113(3):181-185. 10.1016/S0194-5998(95)70102-8

4 

AL Desmond. Vestibular function: evaluation and treatment. New York, Stuttgart: Thieme; 2004.

5 

T Fukuda. The Stepping Test: Two Phases of the Labyrinthine Reflex. Acta Otolaryngol. 1959 Jan 8;50(1–2):95–108. doi:10.3109/00016485909129172

6 

G Guidetti. La basi razionali della terapia delle vertigini. Modena: Ist. Clin. Otolaryngoiatrica Univ.; 1988.

7 

A Hahn. Derzeitige Stand der medikamentösen Therapie der Ménière’schen Erkrankung. In: H Schere, editor. Der Gleichgewichtsinn. Neues aus Forschung und Klinik. 6 Hennig Symposium. Wien, New York: Springer; 2008. p. 159-168.

8 

P Halama. Schwindel – Moderne Diagnostik und Therapie – Presbivertigo. Neurootol Newsletter. 1995;2(1):62-66.

9 

CA Jackson. Dynamic posturography. In: RK Jackler, DE Brackmann, editors. Neurotology. St.Louis, Baltimore, Boston: Mosby; 1994. p. 241-250.

10 

A. Raum Kehaiov, C-F Claussen. Statistische Standards besüglich des Symptomes Schwindel in der Bundesrepublik Deutschland aus der Sicht der Neurootologie. In: C-F Claussen, editor. Differential diagnosis of vertigo. Berlin, New York: Walter de Gruyter & Co; 19801980. p. 481-520.

11 

ТА Khomaziuk, КY Yegorov. General medical practice: dizziness in females with arterial hypertension. Zdorovia Ukrainy. 2010;(3):1-3.

12 

J Kotimaki, M Sorri, E Aantaa, J Nuutinen. Prevalence of Ménière disease in Finland. Laryngoscope. 1999;109:748-753. doi:10.1097/00005537-199905000-00013

13 

JR Kraft. Hyperinsulinemia. The differential marker of idiopathic neurootology with diagnostic/therapeutic application. Neurootol Newsletter. 1996;2 (2):26-30.

14 

T Lempert, H Neuhauser. Epidemiology of vertigo, migraine and vestibular migraine. J Neurol. 2009;256 (3):333-338.

15 

SO McMenomey, SP Gubbels. Labyrintitis. In: PC Weber, editor. Vertigo and disequilibrium: a practical guide to diagnosis and management. New York: Thieme; 2007. p. 91-106.

16 

DA Moffat, RH Balagh. Ménière’s disease. In: AG Kerr, JB Booth, editors. Scott Brown’s Otolaryngology. 3-d ed. Oxford: Butterworth-Heinemann; 1997. p. 1-50.

17 

N Morita, S Kariya, AF Deroee, S Cureoglu, S Nomiya, R Nomiya, T Harada, MM Paparella. Membranous Labyrinth Volumes in Normal Ears and Ménière Disease: A Three-Dimensional Reconstruction Study. Laryngoscope. 2009;119 (11):2216-2220. doi:10.1002/lary.20723

18 

EK Moscicki, EF Elkins, HM Baum, PM McNamara. Hearing loss in the elderly: an epidemiologic study of the Framingham Heart Study Cohort. Ear and Hearing. 1985;6 (4):184-190. doi:10.1097/00003446-198507000-00003

19 

HK Neuhauser, A Radtke, Brevern M von, F Lezius, M Feldmann, T Lempert. Burden of dizziness and vertigo in the community. Arch Intern Med. 2008;168 (19):2118. doi:10.1001/archinte.168.19.2118

20 

M Ojala, L Ketonen, J Palo. The value of CT and very low field MRI in the etiological diagnosis of dizziness. Acta Neurol Scand. 1988;78:26-29. doi:10.1111/j.1600-0404.1988.tb03614.x

21 

H Romberg. Lehrbuch der Nervenkrankheiten. Berlin:Springer-Verlag; 1848.

22 

AH Ropper, RH Brown. Adams and Victor’s Principles of Neurology. 8-th ed. New York, Chicago, San Francisco; 2005.

23 

H Silverstein, HH Wanamaker, SI Rosenberg. Vestibular neurectomy. In: RK Jackler, DE Brackmann, editors. Neurootology. Louis, Baltimore, Boston: Mosby; 1994. p. 945-966.

24 

R Berkow, editor. The Merk Manuel of Diagnosis and Therapy. New York: Merk & Co. Inc. Rahway; 1992.

25 

KF Trinus. Dizziness study test comparison. Archives of sensology and neurootology in science and practice (ASN). 2011;6.

26 

KF Trinus, C-F Claussen. Guidelines on dizziness and space orientation disorders. Neurootology Newsletter. 2012;9(1).

27 

KF Trinus, C-F Claussen. International Clinical Protocol on Vestibular Disorders (Dizziness). Neurootology Newsletter. 2014;10 (1).

28 

KF Trinus, YuA Poskrypko. Role of vestibular analyzer in the ergonomical support of flight safety. Sci Recueill. 1987:92-97.

29 

T Uemura, J-I Suzuki, J Hozawa, SM Highstein. Neurootological examination with special reference to equilibrium function tests. Tokyo:Igaku Shoin Ltd.; 1977.

30 

der Laan FL Van. The ENG diagnosis of perilymph fistulae. Neurootol Newsletter. 1999;4 (1):117-119.

31 

F Waldfahrer, H Iro. Medikamentoese Therapie bei Schwindel. In: C-T Haid, editor. Schwindel aus interdisziplinaerer Sicht. New York-Stuttgart: Georg Thieme Verlag; 2003. p. 206-216.

32 

M Westhofen. Schwindel im Alter. In: Hören und Gleichgewicht. Vienna: Springer Vienna; 2010. p. 161-172. 10.1007/978-3-211-99270-8_17

33 

P Wladislavosky-Waserman, G Facer, et al. Ménière's disease: a 30-year epidemiologic and clinical study in Rochester, MN, 1951-1980. Laryngoscope. 1984;94:1098-1102. Cited in: PubMed; PMID 6611471



Copyright (c) 2017 Sofiia Genyk

Creative Commons License
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.


IFNMU Logo

Free counters!