Training in VEMP

Can You Use VEMPs to Diagnose Meniere's Disease?

Introductory

10 mins

Reading

09 February 2022

Description

Yes VEMPs can be used in a number of ways and, like a number of vestibular diagnostic tests associated with Meniere’s disease, the result and the interpretation depend to a large extent of the point along the disease cycle at which the test is performed. For example, as part of a test battery one use of VEMPs would be to determine the extent of residual otolith function, where reduced VEMP amplitudes or absent VEMPs might be expected as the condition becomes more advanced. However, another interesting application is the VEMP tuning curve, which considers the VEMP amplitude across a range of stimulus frequencies.

In the healthy ear the VEMP (similar concepts apply for both the cervical and ocular VEMP) tuning curve shows a maximal response at around 500 Hz and a progressively reducing amplitude as stimulus frequency increases. However, in a diseased ear the tuning shifts so that the response becomes dominant at around 1000 Hz (Murofushi et al. 2017; Sandhu et al., 2012). The exact mechanism for this shift is unclear but may be attributable to the altered fluid dynamics of the fluid-distended vestibule. Clearly this technique depends on the overall disease stage (e.g. if a VEMP is absent, suggestive of later stages, then a tuning curve cannot be plotted). The postulated mechanism for a tuning curve shift might also suggest that a positive finding should not occur during a remission period even if the patient was a true positive.

To assist you with differentiating Meniere’s disease, see the below tables which suggest expected test results across the test battery in Meniere’s disease patients.

Expected test results in early stage Meniere's disease

Pure tone audiometry	Characterized by an episodic hearing loss affecting the low frequencies
Spontaneous nystagmus	Not present during remission stage Present if seen during an attack Nystagmus can reverse immediately after an attack
Gaze testing	Gaze-evoked nystagmus not present during remission stage Gaze-evoked nystagmus present if seen during an attack
Saccades	Latency: within normal limits Accuracy: within normal limits Velocity: within normal limits
Smooth pursuit	Gain: within normal limits Symmetry: within normal limits
Optokinetic	Gain: within normal limits
Dix-Hallpike	Negative
Head roll	Negative
Caloric test	Total response: reduced Unilateral weakness: larger than 25% toward affected side Directional preponderance: less than 30% Fixation index: less than 50%
cVEMP	Ratio: larger than 36% Amplitude: reduced on affected ear or absent cVEMP Latency: within normal limits
oVEMP	Ratio: larger than 36% Amplitude: reduced on affected ear or absent oVEMP Latency: within normal limits
vHIT lateral	Gain: larger than 0.7 and possibly higher than 1.2 Asymmetry: less than 7% or higher than 7% with increased gain Catch-up saccades: not present or less than 50%
vHIT vertical	Gain: larger than 0.7 and possibly higher than 1.2 Asymmetry: less than 7% or higher than 7% with increased gain Catch-up saccades: not present or less than 50%
Sinusoidal harmonic acceleration	Gain: within normal limits Phase: within normal limits Symmetry: within normal limits
Velocity step test	Time constant: larger than 10 seconds but less than 60 seconds Gain: within normal limits Symmetry: within normal limits

Expected test results in late stage Meniere's disease

Pure tone audiometry	Persistent hearing loss affecting the low frequencies
Spontaneous nystagmus	Nystagmus absent or present only at sub-clinical, slow-phase velocities
Gaze testing	Gaze-evoked nystagmus absent or present only at sub-clinical, slow-phase velocities
Saccades	Latency: within normal limits Accuracy: within normal limits Velocity: within normal limits
Smooth pursuit	Gain: within normal limits Symmetry: within normal limits
Optokinetic	Gain: within normal limits
Dix-Hallpike	Negative
Head roll	Negative
Caloric test	Total response: reduced Unilateral weakness: larger than 25% toward affected side Directional preponderance: less than 30% Fixation index: less than 50%
cVEMP	Ratio: cVEMP absent Amplitude: cVEMP absent Latency: cVEMP absent
oVEMP	Ratio: oVEMP absent Amplitude: oVEMP absent Latency: oVEMP absent
vHIT lateral	Gain: less than 0.7 on affected side Asymmetry: larger than 7% toward affected side Catch-up saccades: generated
vHIT vertical	Gain: less than 0.7 on affected side Asymmetry: larger than 7% toward affected side Catch-up saccades: generated
Sinusoidal harmonic acceleration	Gain: typically reduced, outside of the normative range Phase: increased phase lead above normal range Symmetry: asymmetry toward affected ear
Velocity step test	Time constant: less than 10 seconds Gain: typically reduced, outside of the normative range Symmetry: asymmetry toward affected ear

References

Murofushi, T., Tsubota. M., Suizu, R. and Yoshimura, E. (2017) Is Alteration of Tuning Property in Cervical Vestibular-Evoked Myogenic Potential Specific for Ménière’s Disease? Front. Neurol. 8 Article 193.

Sandhu, J., Low, R., Rea, P., and Saunders, N. (2012) Altered frequency dynamics of cervical and ocular vestibular evoked myogenic potentials in patients with Ménière’s disease. Otol Neurotol 33. Pages 444-449.

Disclaimer

The information in the figures are a resource tool based on the needs of medical professionals and students that allows quick access to the typical assessment findings in a range of common vestibular disorders. The resource was developed to provide fast, easy-to-use, and always available information which can aid in reaching the correct diagnosis. The information contained within is provided as an information resource only, and should not be used as a substitute for professional diagnosis and management.

Presenter

Michael Maslin

After working for several years as an audiologist in the UK, Michael completed his Ph.D. in 2010 at The University of Manchester. The topic was plasticity of the human binaural auditory system. He then completed a 3-year post-doctoral research program that built directly on the underpinning work carried out during his Ph.D. In 2015, Michael joined the Interacoustics Academy, offering training and education in audiological and vestibular diagnostics worldwide. Michael now works for the University of Canterbury in Christchurch, New Zealand, exploring his research interests which include electrophysiological measurement of the central auditory system, and the development of clinical protocols and clinical techniques applied in areas such as paediatric audiology and vestibular assessment and management.