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Author: admin | 20.03.2014 | Category: Tinnitus Causes And Treatments

High intensity auditory signals not only stimulate the cochlea but also activate the vestibular system and can evoke short latency sound evoked reflexes in several muscles including the anterior neck muscles and extraocular muscles.
One of the clinical limitations of VEMP tests is that, as with most vestibular tests, VEMPs assess site of lesion, not necessarily the presence or absence of disease. Despite the limitations, there is at least one vestibular pathology where VEMP tests are extremely useful and, in fact, measure the presence of disease. Dehiscence of the bone overlying the superior SCC is termed superior semicircular canal dehiscence, or SCD. SCD is typically confirmed using high resolution temporal bone computerized tomography (CT). VEMP tests can be used to detect whether a dehiscence is causing pathological pressure transmission in the vestibular labyrinth, and are therefore uniquely suited for the identification of SCD. For all intents and purposes, the cVEMP threshold is an excellent diagnostic tool for patients with SCD.
Table 2 summarizes the old and new recommendations for SCD detection using cVEMP and oVEMP tests. Below, we present a case study illustrating the utility of oVEMP testing in the identification of SCD.
The patient was a 58-year-old woman seen in the Duke Vestibular Lab due to complaints of spinning vertigo, lasting seconds, which occurred when bending over and was accompanied with increased aural pressure in the right ear. An audiogram was obtained from an outside facility and showed a mild low-frequency conductive hearing loss at 250 Hz in the right ear and a mild high frequency SNHL bilaterally.
Videonystagmygraphy (VNG) including ocular motility, positional testing, and caloric testing was normal. Though the CT scan identified bilateral SCD, based on symptoms and oVEMP results the patient was ultimately diagnosed with SCD in the right ear only. The above case study shows a patient presenting with bilaterally normal cVEMP thresholds, a pathologically increased oVEMP amplitude in the right ear only, a low frequency conductive hearing loss in the right ear, and a CT scan interpreted as showing a bilateral dehiscence. The Canadian Academy of Audiology is dedicated to enhancing the role of audiologists as primary hearing health care providers through advocacy, education and research. Fireworks have a sound decibel of 150, and ear protection is recommended for decibels above 85, says Jyoti Bhayani, certified audiologist at Loyola University Health System's Gottlieb Memorial Hospital.
The following article has been re-published with permission from its author, the American Speech-Language-Hearing Association (ASHA). Hearing screening tests provide a quick and cost effective way to separate people into two groups: a pass group and a fail group. Hearing screening occurs from birth throughout the adult years when requested, when conditions occur that increase risk for hearing loss, or when mandated by state and local laws or practices.
It is recommended that all hearing screening programs be conducted under the supervision of an audiologist holding the American Speech-Language-Hearing Association’s (ASHA) Certificate of Clinical Competence (CCC).
Hearing screening for newborns before they leave the hospital or maternity center is becoming a common practice. Screening procedures for newborns and infants can detect permanent or fluctuating, bilateral or unilateral, and sensory or conductive hearing loss, averaging 30 to 40 dB or more in the frequency region important for speech recognition (approximately 500-4000 Hz). Otoacoustic emissions are inaudible sounds from the cochlea when audible sound stimulates the cochlea.
Auditory brainstem response is an auditory evoked potential that originates from the auditory nerve.
ASHA-certified audiologists (and state licensed where applicable) should be designated as the manager of these screening programs.
Infants who do not pass a screening are often given a second screening to confirm findings and then referred for follow-up audiological and medical evaluations that should occur no later than 3 months of age. Even if the infant passes screening, certain conditions do not produce immediate hearing loss. The Individuals with Disabilities Education Act (IDEA) in its regulations requires states to develop and implement a statewide system of early intervention services for infants and toddlers.
Hearing Sparks is a way for me to share my story of hearing loss, as well as news about accessibility, and other geeky stuff about deafness. These reflexes can easily be recorded with surface electrodes placed either on the sternocleidomastoid muscle (SCM) or in proximity to the inferior oblique (extraocular) muscle.1–3 The evoked response is referred to as a vestibular evoked myogenic potential (VEMP).
VEMP tests also assess the right and left labyrinth separately, making VEMPs further useful in localizing side of lesion. That is, one of the best uses of the VEMP lies in its ability to help in the diagnosis of superior semicircular canal dehiscence (SCD).


These patients tended to complain of odd symptoms such as vertigo when sneezing, hearing their eyes move, and sensitivity to loud sounds.
Whereas the cochlear system is comprised of two openings (the oval and round windows) and has relatively low impedance, the vestibular fluids are essentially incompressible, in a healthy system, and minimally affected by sound pressure. In other words, there is a great deal of overlap in cVEMP amplitude between healthy individuals and those with SCD.17 For this reason, the VEMP parameter of most interest for the identification of SCD has been the cVEMP threshold. They reported that using a 4000 Hz tone burst at 120 dB SPL for air conduction and 130 dB FL for bone conduction adequately separated all 22 SCD patients from 22 healthy subjects in their study cohort.
She reported a constant fullness in the right ear, exacerbated by bending over, for several years that was extremely bothersome. Tympanometry showed normal middle ear pressure and compliance and normal equivalent ear canal volumes bilaterally. The radiologist reported a “bony dehiscent of the superior semicircular canal bilaterally” (see Figure 3).
Coronal view of CT scan of patient presenting with right-sided symptoms and abnormal oVEMP on right side. However, based on the possibility of false positives, current research strongly argues that “CT should not be used in isolation for the diagnosis of SCD”14 and that the “low specificity of CT scans creates a risk for over diagnosis of SCD if the coronal CT scans are not correlated with clinical symptoms.”16 VEMP testing provides an excellent and relatively inexpensive test that should be completed prior to exposing the patient to radiation, that may or may not be warranted, or after a positive CT scan to confirm the presence of abnormal pressure transmission prior to the patient undergoing surgery. Vestibular evoked potentials in human neck muscles before and after unilateral vestibular deafferentation. Vestibular-evoked extraocular potentials produced by stimulation with bone-conducted sound. Ocular vestibular evoked myogenic potentials (OVEMPs) produced by air- and bone-conducted sound. Vestibular evoked myogenic potentials in the sternomastoid muscle are not of lateral canal origin.
A critical review of the neurophysiological evidence underlying clinical vestibular testing using sound, vibration and galvanic stimuli.
The diagnostic value of vestibular evoked myogenic potentials in patients with Meniere's disease. Abnormality of cervical vestibular-evoked myogenic potentials and ocular vestibular-evoked myogenic potentials in patients with recurrent benign paroxysmal postitional vertigo.
Multislice computed tomography in the diagnosis of superior canal dehiscence: how much error, and how to minimize it? Clinical and diagnostic characterization of canal dehiscence syndrome: a great otologic mimicker.
Air-conducted oVEMPs provide the best separation between intact and superior canal dehiscent labyrinths. Testing vestibular-evoked myogenic potentials with 90-dB clicks is effective in the diagnosis of superior canal dehiscence syndrome. Vestibular-evoked myogenic potentials in the diagnosis of superior canal dehiscence syndrome.
Vestibular hypersensitivity to sound (Tullio phenomenon): structural and functional assessment.
Ocular versus cervical VEMPs in the diagnosis of superior semicircular canal dehiscence syndrome. An indicator of probable semicircular canal dehiscence: ocular vestibular evoked myogenic potentials to high frequencies. Vestibular-evoked myogenic potential thresholds normalize on plugging superior canal dehiscence. Piker, Aud, PhD, is an assistant professor in the Division of Otolaryngology-Head and Neck Surgery at Duke University Medical Center in Durham, NC. Without such programs, average age of detection of significant hearing loss is approximately 14 months.
Children are more likely to perform below their grade level, and are more likely to be held back, drop out of school, and fail to earn a high school diploma. The outer hair cells of the cochlea vibrate, and the vibration produces an inaudible sound that echoes back into the middle ear. It is required that infants and toddlers with disabilities be identified and evaluated using at risk criteria and appropriate audiologic screening techniques. Once I got a handle on the face shapes, I looked through tons of books to find the styles I liked.
Figure 1 illustrates examples of a cVEMP and an oVEMP waveform recorded from a healthy adult.


Another advantage is that both these tests are relatively fast and very tolerable for patients. Further, cVEMPs are hypothesized to be useful in Meniere’s disease, another diagnosis based on clinical history and audiometric findings, because the saccule is believed to be the most involved structure in endolymphatic hydrops, following the cochlea. In other words, CT scans have a high sensitivity but can produce false negatives resulting in a low specificity for the diagnosis of SCD.
With a dehiscent canal, the sound pressure causes greater stimulation of the vestibular end organs than would otherwise be expected in a normal functioning labyrinth.
Thus, oVEMP amplitude not only has better response characteristics than cVEMP threshold for the identification of SCD, it can be completed using a single sound intensity thus limiting the patient exposure to multiple runs of intense sound and muscle fatigue.
All 22 SCD patients generated an oVEMP in response to 4000 Hz, whereas not a single one of their 22 healthy control subjects did. Her major symptoms were aural fullness in the right ear and chronic disequilibrium, which reportedly occur in 62–73% of patients with SCD.14,15 Based solely on her symptoms and normal cVEMP thresholds, a diagnosis of SCD would most likely not have been reached and she would have continued to search for an answer to her symptoms, resulting in an increase in healthcare costs as she sought out new specialists. Further, the most current literature suggests that the oVEMP has a greater sensitivity and specificity for the identification of SCD than the cVEMP.
Those who fail are in need of an in-depth evaluation by an audiologist and may also need follow-up care from other professionals. These consequences are in sharp contrast to those for children who are identified early, receive early intervention, and then are found to function at the level of their peers by the time they enter school. Electrodes are placed on the head, and brain wave activity in response to sound is recorded. After a hearing loss is confirmed, coordination of services should be facilitated by the infant’ s medical manager and the IDEA coordinating agencies.
However, one of the biggest limitations of VEMP tests is that the response rate decreases in older patients. Caloric and rotary chair tests do not assess the saccule and may underestimate vestibular impairments in Meniere’s disease. Patients with SCD often report a cluster of vestibular and auditory symptoms, the most commonly reported shown in Table 1. The result is often an increase in the amplitude of the VEMP and an abnormally low VEMP threshold. She had been seen by several otolaryngologists but was unable to find a diagnosis for her symptoms. The arrow was placed by the radiologist onto the image to indicate a possible dehiscence over the superior semicircular canal. Conversely, relying solely on her CT report would result in a diagnosis of bilateral SCD, which may have caused an increase in health anxiety for the patient given her lack of symptoms on the left side. And once hearing is damaged, it cannot be repaired,” said Jyoti Bhayani, certified audiologist at Gottlieb Memorial Hospital, part of Loyola University Health System.
ABR can detect damage to the cochlea, the auditory nerve and the auditory pathways in the stem of the brain. Consequently, both cVEMPs and oVEMPs have been proven useful in assessing the presence of SCD.
Fortunately, the oVEMP was strongly suggestive of right-sided SCD and, given the oVEMP results and her symptoms, she received a diagnosis of right-sided SCD and her anxiety was relieved.
Replication studies need to be completed in order to confirm the sensitivity and specificity of the oVEMP amplitude and 4000 Hz oVEMPs for the identification of SCD.
Piker’s primary research interests are in the areas of vestibular sciences and balance disorders where she works as both a clinical audiologist and a clinician-scientist. One in 10 Americans has hearing loss that affects his or her ability to understand normal speech. However, to date, research suggests the oVEMP is the single most sensitive test in the diagnosis of SCD.
OAEs can detect blockage in the outer ear canal, middle ear fluid, and damage to the outer hair cells in the cochlea.
Bhayani, who regularly cares for construction and factory workers, frequent air travelers and seniors in her practice at Gottlieb Memorial Hospital.



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