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How to cite this article Benecke H, Perez-garrigues H, Sidek Db, Uloziene I, D K, Sondag E, Theeuwes A, et al. Betahistine is widely used in the management of vertigo but clinical research into this indication1-3 has not been accompanied by extensive investigation of its impact on health-related quality of life (HRQoL). Preliminary baseline data from this study have been the subject of a separate publication4. This was an international, multicentre, open-label, post-marketing surveillance (PMS) study of betahistine in patients with vertigo of peripheral vestibular origin, undertaken in the context of routine primary care. Three well-established instruments - the DHI, HADS and SF-36v2 - were used to evaluate efficacy.
For the DHI and HADS, if at least 50% of items were completed in any given subscale, any missing values were assumed to be equal to the mean of the relevant subscale. Missing data on the SF-36v2 Health Surveys was dealt with by substituting a person-specific estimate derived from the mean response to the answered items in the same scale when a respondent had answered at least one-half of the items on that scale; if fewer than half the items were completed the score was considered as missing. Each of the efficacy parameters (DHI total score, HADS total score, SF-36v2 scores and scores on the different subscales) were summarized by descriptive statistics by visit, including last visit on-treatment. Subgroup analyses were performed to explore potential relations between a specific subgroup (gender, disease type, betahistine dosage, country, betahistine treatment at baseline) and the major efficacy variables. Safety assessment was based on the safety population, which included all patients allocated to treatment who received a prescription of betahistine at baseline and who had at least one subsequent clinic visit. Reports of adverse drug reactions (ADRs) that started during the study were obtained during the follow-up and final visits, and coded according to the Medical Dictionary of Regulatory Activities (MedDRA) classification version 9.0. The statistical analyses of the efficacy data were descriptive, and usually limited to mean ± standard deviation (SD). The study investigators were general practitioners and specialists based at 389 centres located in the following 13 countries: Brazil (3 centres), Canada (16 centres), Croatia (12 centres), Hungary (52 centres), India (23 centres), Latvia (42 centres), Lithuania (45 centres), Malaysia (17 centres), Poland (39 centres), Romania (88 centres), Russia (24 centres), Slovenia (11 centres) and Spain (17 centres). Data management and statistical analysis were the responsibility of FOVEA Group (Rueil Malmaison, France). The study was designed and conducted in accordance with the international principles of Good Clinical Practice and the provisions of the Declaration of Helsinki and later amendments. Informed consent was obtained from each patient in accordance with local regulatory requirements before they were enrolled in the study. A safety population of 2032 patients was recruited, from which an efficacy population of 1898 persons was derived. A full listing of correlations between DHI, SF-36v2 and HADS scores with a Pearson coefficient > 0.60 (regardless of sign) is presented in Table 3.
The most frequently reported ADRs were gastrointestinal disorders (33 events in 27 patients, principally abdominal pain upper, nausea or dyspepsia) and nervous system disorders (14 events in 13 patients, principally headaches). Forty-three ADRs in 28 patients were classified as "possibly" and 11 events in 9 patients were classified as "probably" related to use of study medication; the remaining 22 events were regarded as either unlikely (n = 19) or were unknown (n = 3).
OSVaLD is the largest study of its kind in patients with vertigo, in terms both of the total number of patients enrolled and their geographic and ethno-cultural diversity. Recent exercises in the use of outcomes such as HRQoL to examine the effects of vertigo15-18 originate from the recognition that diseases of the peripheral vestibular system can have wide-ranging physical and psychological effects on the lives of patients19,20.
The primary efficacy criterion evaluated was the absolute change from baseline in mean total DHI score between the baseline and final (3-month) visits. This study is the first of its kind to use both the SF- 36v2 and the HADS to evaluate the effect of betahistine on vertigo patients. All the correlations identified were compatible with a priori expectations: so, for example, the more the SF-36v2 PCS signified improvement in clinical condition, the more the DHI total score did also. Further perspective on the effects of betahistine in this study may be extracted from reference to the fact that the overall result of the study was replicated in the large subset of patients with an initial diagnosis of BPPV (n = 417). OSVaLD was an open-label observational study; this is a format with recognized limitations30, but it was appropriate for an international study in the context of routine care and addressed certain limitations of controlled trials, such as strict limitations on patient eligibility and the use of co-medications. Preparation of this report was assisted by staff of Hughes associates, 3 Collins Street, Oxford OX4 1XS, UK. Brazil (3 centres): Boari L (Sao Paulo), Chaves AG (Sao Paulo), Dorigueto RS (Sao Paulo), Gananca FF (Sao Paulo), Goncalves DU (Belo Horizonte), Hyppolito MA (Ribeirao Preto), Korn GP (Sao Paulo), Munhoz MSL (Sao Paulo), Oliveira JAA (Ribeirao Preto). Croatia (12 centres): Aras I (Zagreb), Bencic I (Rijeka), Bonifacic M (Omisalj), Branica S (Zagreb), Dovzak-Kokic D (Split), Drvis P (Zagreb), Gortan D (Zagreb), Grdinic B (Pula), Grigic J (Osijec), Handzic I (Zagreb), Ivkovic M (Zagreb), Juros V (Sibenik), Kovacic J (Zagreb), Krstic E (Zadar), Lucin Z (Split), Maksimovic Z (Osijek), Maslovara S (Osijek), Rak I (Zagreb), Resler Seks A (Zagreb), Ries M (Zagreb), Trotic R (Zagreb).
Hungary (52 centres): Rosenberg A (Budapest), Gaal A (Szentendre), Badacsonyi M (Balmazujvaros), Balogh G (Budapest), Bandula M (Szigetszentmiklos), Baranya E (Szolnok), Jeges B (Veszprem), Brajnovits T (Budapest), Bucsai A (Szeged), Tubony Cs (Veszprem), Csill R (Budapest), Czegledi I (Szolnok), Olah L (Debrecen), Draveczky E (Pecs), Vaszkun L (Dunaujvaros), Siro E (Balatonfured), Fain A (Tatabanya), Foth A (Budapest), Gerlinger I (Pecs), Gestelyi Gy (Debrecen), Getachen K (Nagykanizsa), Ghayada R (Budapest), Gilincsek L (Kaposvar), Guth I (Hatvan), Hegedus E (Zalaegerszeg), Hegyi I (Mezobereny), Jofeju E (Siofok), Kerepesi L (Cegled), Krisan I (Bekescsaba), Laszlo K (Budapest), Lorincz T (Szekesfehervar), Marisch I (Rackeve), Mihalecz K (Nagykanizsa), Breznyan M (Dunaujvaros), Mori I (Budapest), Nagy L (Budapest), Manhalter N (Budapest), Pal A (Budapest), Papp M (Budapest), Peter J (Zalaegerszeg), Prunk Eger F (Nagykata), Radai F (Kaposvar), Szihalmy I (Eger), Torma E (Bekescsaba), Torok K (Szeged), Trencsenyi Gy (Vac), Varga E (Budapest), Vincze A (Szeged), Vogel R (Budapest), Szakolczay Z (Gyor), Zsilinszky Z (Budapest), Fain A (Tatabanya), Rovo Zs (Budapest), Tamas L (Budapest), Mester B (Papa), Hudak I (Mateszalka), Toth L (Debrecen), Merczel A (Gyor). India (23 centres): Agarwal VK (Varanasi), Bhatia R (Lucknow), Bhimani B (Rajkot), Biswal RN (Cuttack), Biswas A (Kolkata), Chowdary VS (Hyderabad), Dhond P (Mumbai), Dube TN (Bhopal), Gopakumar G (Calicut), Kansara A (Ahmedabad), Khound G (Guwahati), Kirtane MV (Mumbai), Mukherjee A (Kolkata), Nagpal T (Jabalpur), Ravikumar A (Chennai), Reddy V (Hyderabad), Sampat N (Mumbai), Shaikh S (Pune), Sinha S (Midnapur), Vaid N (Pune), Valsangkar S (Solapur), Vasnoi S (Dehradoon), Vishwanathan A (Coimbatore). Latvia (42 centres): Blumberga I (Riga), Bucina B (Jelgava), Cakule G (Renda), Demidova L (Riga), Dolge A (Riga), Dzirgause M (Riga), Freimane A (Valmiera), Fricbergs J (Riga), Frolova V (Riga), Ganus I (Incukalns), Gavare I (Aizkraukle), Grigs V (Aizkraukle), Grusle M (Rujiena), Levins E (Ogre), Veidule I (Talsi), Indrane M (Carnikava), Saihulova I (Jelgava), Jeca A (Riga), Jegere D (Riga), Ivanova A (Ventspils), Kalitas N (Riga), Kalnina Z (Riga), Kanepe K (Riga), Karlovska M (Riga), Kokina I (Pampali), Krigere R (Riga), Krisjane D (Aizkraukle), Kukurane S (Olaine), Kundrate G (Aloja), Kukaine S (Ligatne), Kukute I (Bauska), Lagzdina L (Kuldiga), Lapsa-Arenta S (Bauska), Madre S (Liepaja), Matusevica A (Riga), Mezale I (Riga), Melnika V (Riga), Mickevica S (Riga), Morlata N (Riga), Naudina MS (Riga), Nimroda L (Riga), Norina D (Limbazi), Opelte V (Saldus), Pavlovska I (Aizpute), Priede Z (Riga), Proskurna T (Riga), Purina J (Riga), Kamsa I (Riga), Raumane D (Riga), Kenina V (Riga), Roska-Levina D (Ogre), Rozenbaha A (Riga), Rozkalne A (Riga), Ruta A (Riga), Sendze G (Ventspils), Silins A (Jelgava), Skrupska D (Olaine), Skurule I (Incukalns), Sokalska A (Riga), Stepko Z (Liepaja), Supe I (Riga), Telezenko I (Riga), Tretjaka N (Riga), Turlaja V (Riga), Uzbeka I (Valka), Valucka T (Riga), Vancans J (Balvi), Vasilevskis U (Skujene), Veinberga V (Riga), Viba Z (Riga), Vitkovska M (Riga), Vitolina A (Riga), Voitovica L (Riga), Zigure I (Alukse), Zilite I (Bauska). Lithuania (45 centres): Bakstiene J (Gargzdai), Balkaitiene R (Utena), Basinskiene V (Kaunas), Beinaraviciene R (Vilnius), Bertasiene Z (Klaipeda), Bieliauskiene I (Marijampole), Budrikiene N (Vilnius), Butkus A (Kaunas), Butkus E (Siauliai), Butkus R (Sakiai), Cholomskiene V (Taurage), Dainius K (Radviliskis), Degteriova R (Vilnius), Deveikyte A (Vilnius), Dirzauskiene J (Klaipeda), Einoriene D (Birzai), Gadeikis E (Siauliai), Gircys P (Klaipeda), Grazeviciute L (Vilnius), Ivaskevicius A (Moletai), Janciute J (Kaunas), Jankauskiene D (Jurbarkas), Jersova J (Vilnius), Jociene I (Vilnius), Jokimaitiene J (Vilnius), Jukneliene R (Alytus), Kanapeckiene V (Radviliskis), Karaliene V (Kaunas), Kazlauskas A (Siauliai), Kicas R (Sakiai), Kiskuniene I (Vilnius), Kiudelis A (Taurage), Kizlaitiene R (Vilnius), Kuriene A (Jurbarkas), Lukaseviciene N (Klaipeda), Lukosaitis A (Siauliai), Malikeniene T (Kilnius), Markeleviciene R (Vilnius), Mazonyte S (Klaipeda), Nadusauskiene M (Kedainiai), Narkeviciene V (Vilnius), Naumcik J (Elektrenai), Navickiene E (Vilnius), Pancyreva I (Vilnius), Pavydyte J (Svencionys), Persidskaja O (Vilnius), Petkiniene V-R (Jubarkas), Petrileviciene R (Kedainiai), Petrosiute B (Kelme), Pliopliene I (Kaunas), Puckiene Z (Siauliai), Razukiene J (Vilnius), Remeikiene S (Grigiskes-Vilnius), Rudzeviciene E (Kaunas), Sceponaviciute S (Siauliai), Scerbickiene L (Rokiskis), Sersniova I (Vilnius), Sinkuniene N (Panevezys), Skerneviciute I (Telsiai), Snureviciute V (Kedainiai), Sostakiene N (Gargzdai), Tunkulas E (Vilnius), Vitkauskiene V (Telsiai), Zakarauskiene R (Kaunas), Zorjan N (Klaipeda), Zurauskiene R (Kaunas). Malaysia (17 centres): Abdullah Sani (Kuala Lumpur), Amran Mohamad (Kuala Terengganu), Asma Abdullah (Kuala Lumpur), Avatar Singh (Kuching), Baharudin Abdullah (Kota Bharu), Dinsuhaimi Sidek (Kota Bharu), Faridah Hassan (Selayang), Ganeshwaran Selvarajah (Klang), Goh Bee See (Kuala Lumpur), Gurdeep Singh Mann (Ipoh), Harvinder Singh (Ipoh), Hj Abdul Razak Hj Ahmad (Melaka), Iskandar Hailani (Kuala Lumpur), Izzuniddin Mohd Yusof (Melaka) , K Gopalan Nair (Seremban), KS Sathananthar (Kuantan), Kuljit Singh (Kuala Lumpur), Lokman Saim (Kuala Lumpur), Melati Hj Abdul Ghani (Johor Bharu), Michael Herg (Seremban), Mohd Amin Jalaludin (Kuala Lumpur), Mohd Khairi Md Daud (Kota Bharu), Mohamad Khir Abdullah (Johor Bharu), Nazim Hj Noor (Kota Bharu), Nezrean Radzana Mohamed (Johor Bahru), Nor Kamaruzaman Esa (Melaka), Noraffendie Mat Jusoh (Kuala Terengganu), Prepageran Narayanan (Kuala Lumpur), Pua Kin Choo (Penang), Raja Ahmad Al'Konee (Kuantan), Raman Rajagopalan (Kuala Lumpur), Rosmaliza Ismail (Kuantan), Siti Sabzah Mohd Hashim (Alor Star), Sivakumar Kumarasamy (Alor Star), Tan Lye Suan (Klang), Tengku Mohamed IzamTengku Kamalden (Johor Bharu), Tiong Tung Sang (Kuching), Valuyeetham Kamara Ambu (Seremban), Wan Islah Leman (Kuantan), Zainal Azmi Zainal Abidin (Selayang), Zulkiflee Salahuddin (Kuantan), Zulkifli Yusof (Alor Setar). Poland (39 centres): Burduk P (Bydgoszcz), Chmura H, Czecior E (Zabrze), Dabrowski P (Poznan), Diechota L (Wejherowo), Dietrich G (Gdansk), Domagata M (Raciborz), Durko M (Lodz), Frak W (Lublin), Franczuk-Gwiazda M (Pruszkow), Galbarczyk D (Ciechanow), Gaweowicz J (Lublin), Kabacinska A (Szczecin), Kadej GZ (Siedlce), Kapuscinski J (Wroclaw), Kolebacz B (Katowice), Korpus-Kaminska I (Lodz), Lachowicz M (Biatystok), Mielnik E (Ketrzyn), Mihutka S (Pruszkow), Nilewski J (Gdansk), Nouinska E (Zabrze), Obzebowska- Karszania Z (Suchylas), Oleksiak M (Katowice), Palasik W (Warsaw), Paradowski B (Wroclaw), Paskal J (Zary), Pospiech L (Wroclaw), Pres K (Wroclaw), Rynio E (Stargaro), Schneider K (Tarnow), Siger M (Lodz), Stoniewska-Piackus M (Gdansk), Szczuto J (Zielona Gora), Wilczynski K, Wojcicki P (Lublin), Woynowski W (Skorzewo), Zatonski T(Wroclaw), Ziolkowska-Kochan M (Bydgoszcz), Zygadlo EN. Russia (24 centres): Alekseeva N (Moscow), Amelin A (St Petersburg), Artemova I (Moscow), Batysheva T (Moscow), Bobyreva S (Moscow), Boyko A (Moscow), Buldakova N (Moscow), Ganzhula P(Moscow), Gaponova O (Moscow), Hanevich T (Moscow), Hozova A (Moscow), Isachenkova O (Moscow), Ismailov A (Moscow), Zhuravleva E (Moscow), Kostenko E (Moscow), Lilenko S (St Petersburg), Lisenker L (Moscow), Makarova G (Moscow), Manevich T (Moscow), Matsnev E (Moscow), Melnikov O (Moscow), Morozova S (Moscow), Nesterova O (Moscow), Nikulina I (Moscow), Otcheskaya O (Moscow), Pivovarova V (Moscow), Rotor L (Moscow), Rylskiy A (Moscow), Shalabanova I (Moscow) , Shinkarev S (Moscow), Sorokoumov V (St Petersburg), Vdovichenko T (Moscow), Vinetskiy Y (Moscow), Vostricova I (Moscow), Zadorozhnaya T (Moscow). Slovenia (11 centres): Breznik Farkas B (Murska Sobota), Felbabic J (Novo Hesto), Geczy Buljovcic B (Ljubljana), Grad A (Ljubljana), Hoenigman B (Sempeter), Kurent Z (Ljubljana), Krek BP (Kranj), Rok B (Ljubljana), Spindler M (Maribor), Vatovec J (Ljubljana), Zorn A (Izola), Zupan L (Celje). Spain (17 centres): Aguila Artal A (Sabadell), Caballero Borrego M (Barcelona), Garcia Vazquez C (Pontevedra), Cruellas Taishiv F (Hospitalet de Llobregat), Munoz Pinto C (Alicante), Domenech Juan I (Hospitalet de Llobregat), Donderis Sala J (Valencia), Estevez Garcia M (Vigo), Pallas Pallas E (Vigo), Grani Martinez F (Lleida), Gonzalez Compta FX (Hospitalet de Llobregat), Galindo Ortega J (Lleida), Garcia Arumi AM (Barcelona), Garcia Gonzalez B (Lleida), Gonzalez Guijarro I (Vigo), Hernandez Agelet de Saracibar A (Lleida), Hijano Esque R (Barcelona), Lopez Escamez JA (El Ejido), Saiz Arnaiz JM (Sabadell), Izquierdo Luzon J (Alicante), Perez Lopez L (Valencia), Paya Perez LM (Alicante), Mesa Marrero M (Viladecans), Molina Palma MI (El Ejido), Navarrete Alvaro LM (Barcelona), Marti Gomar L (Valencia), Melgarejo Moreno F (Lleida), Orts Alborch M (Valencia), Suarez Granda PI (Valencia), Perez Monteagudo P (Alzira), Perez Garrigues H (Valencia), Perez Guillen V (Valencia), Rodriguez Rondon S (Valencia), Santos Perez S (Santiago de Compostela), Soto Varela A (Santiago de Compostela), Malluguiza Calvo JR (Alicante), Ramirez Llorens R (Alzira), Jimenez Montoya R (Hospitalet de Llobregat), Barona de Guzman R (Valencia), Escamilla Carpintero Y (Sabadell), Saiz Monfort V (Alzira), Gisbert Aguilar FJ (Alzira), Provedo Poza C (Vigo), Pardo Salgado E (Vigo), Aleman Lopez O (Alicante), Martin Sanz E (Valencia), Marco Algarra J (Valencia). The Brain Electrical Activity Mapping (BEAM) of Vestibular Evoked Potentials (VestEP) is a new method in the toolbox of the neurootologist. The aim of following two case presentations is to demonstrate the method of cortical Vestibular Evoked Potentials (VestEP) displayed by its combination with Brain Electrical Activity Mapping (BEAM).1 The VestEP-BEAM method provides reliable clinical information about the functional state of the vestibular endorgan, its brain stem pathways and cortical representation.
A 47-year-old male was referred in 1995 to the Neurootology department with a presumed diagnosis of total bilateral vestibular loss. 1980 - Right otitis herpetica with right facial palsy and the complication of encephalitis herpetica with resultant progressive severe hearing and vestibular loss right. Absent potentials for the left ear and pathological morphology of the curves, with prolonged interpeak latency of the waves III-V for the right ear.
These could be cognitive potentials due to proprioceptive stimuli, coming from cervical and body receptors. A 57-year-old male was referred to our department in September 1995 for neurootologic investigation, for a presumed diagnoses of complete bilateral vestibular loss and suspicion of right acoustic neurinoma. Delayed acoustic brain stem evoked potentials, to the level of the Colliculus inferior, bilaterally, with either left and right stimulation. Normal image of cerebello-pontine angle, meatus acousticus intern us, VIIIth cranial nerve, cochlea, and semicircular canals. We recommended therapy with Betahistine (Vasomotal®) 8 mg x 3 times daily and a follow-up examination after three months. The patient returned after three months of therapy with unchanged bilateral tinnitus and reported a slight amelioration of the hearing, which was objectified with audiometric testing (10dB at the right ear, 5 dB at the left ear). Central (probably mesencephalic) vestibular affection, with inhibition of the nystagmus generator centers.Bilateral affection of the acoustical receptors and probably of the brain stem acoustical pathways. The patient was recommended to continue therapy with Betahistine, and to make supplementary cardiovascular and blood tests (coagulation study, serum cholesterol and triglyceride etc).
In the first case, where the symptomatology is dominated by the severe disequilibrium complaints, this diagnosis is confirmed by the VestEP-BEAM investigation. In the second case, any symptoms suggesting an affection of the vestibular system are absent. We thank Christo Kolchev, MD, Neurologist, for his excellent scientific discussions and advice. RESULTS: We found 45 articles, 15 of these made up the study by fitting either the inclusion factors. CONCLUSION: VEMP may be useful as hearing recovery predictor in patients with sudden sensorineural hearing loss, justifying the implementation of such examination in this population. Sudden sensorineural hearing loss or sudden deafness is characterized as a hearing loss of abrupt onset, usually unilateral, with no known cause. It's an emergency in otology and affects mainly the fourth decade of life and affects 5 to 20 people out of 100 thousand individuals per year and it is estimated that there are about 4000 new cases per year in the United States and 15,000 worldwide, with equal distribution in relation to gender4-6. They are hypotheses to explain the etiology of sudden deafness as the vascular hypothesis, viral hypothesis, the autoimmune hypothesis and the membrane rupture hypothesis. The Vestibular Evoked Myogenic Potential is an electrophysiological test that evaluates the goal via spinal hall. The history of this examination is relatively recent as though their first date back to 1964 reports, only in 1994 were published the first studies suggesting clinical application for Evoked Myogenic. For review of the vestibular pathway that cannot be analyzed by the other entrance exams, the exam has been gaining attention in the labial battery evaluation. The aim of this study was to investigate the clinical applicability of Vestibular Evoked Myogenic Potentials in patients with sudden sensorineural hearing loss. This is a systematic review that followed the precepts of the Cochrane Handbook11 as the formulation of the question, location, selection and critical evaluation of the articles.
Using the extracted descriptors of Medical Subject Headings (MeSH), was established the following advanced search strategy in PubMed, 'vestibular evoked myogenic potentials' associated by the Boolean operator AND to 'hearing loss, sudden'.
In the LILACS and SciELO database, we used the indexed descriptors Descriptors in Health Sciences (MeSH), according to the following strategy: Perda auditiva subita AND Potenciais evocados. It was considered as inclusion criteria articles in English, Portuguese or Spanish, published in the last two decades that associate sudden sensorineural hearing loss and vestibular evoked myogenic potentials.
Abstracts of pre-selected articles were assessed by two reviewers, were selected for analysis those correlated descriptors.
Data were tabulated covering the following information: authors, place and year of publication, sample size (n), objectives and type of study (Table 1).
The 45 articles found, 11 were excluded due to language, to be present at duplicate or not correlate the descriptors.
About the type of study 53% were prospective, 6 longitudinal studies10,12-16 and two transverse17,18, 33% were restrospectives19-23, 7% case study24 and 7% Bayesian cure rate model25.
The objective of 60% of the studies was to determine whether the Vestibular Evoked Myogenic Potential (VEMP) can be used as a predictor of hearing recovery in patients with PANSS10,12-16,19,20,23. Among the studies that have investigated the use of objective tests in the management of patients with PANSS some noteworthy. Study conducted in Japan, with 22 patients with PANSS and single episode of vertigo, revealed that 77% and 45% showed VEMP and caloric test changed, respectively. Prognostic factors of patients with PANSS and worse hearing threshold than 70 dB, and its relationship with hearing and vestibular tests were investigated.
Trying to minimize the uncertainties surrounding the hearing recovery of patients with sudden sensorineural hearing loss was developed a predictive model of evolution by reference audiological tests (audiometry, DPOAE, VEMP and ABR) and other variables considered as prognostic factors.
Many studies have sought to elucidate whether the Vestibular Evoked Myogenic Potential can be a useful predictor of hearing recovery in patients with sudden sensorineural hearing loss, which is a positive relationship in most of them, justifying the implementation of such examination in this population. Paper submitted to the ITJ-SGP (Publishing Management System) on December 21, 2014; and accepted on March 19, 2015.
Patients affected with multiple sclerosis (MS) frequently suffer from vestibular disorders due to vestibulospinal involvement.
Frequently, patients with definite multiple sclerosis (MS) are known to report symptoms related to vestibular disorders in the course of their illness.
VEMPs do not require any specific skill on the part of patients, and they may be investigated in all patients who are able to remain seated. Recent studies showed that rarefaction clicks are preferred for evoking the saccular response and that the sternocleidomastoid muscle (SCM) is the most advisable recording site [6].
In MS patients whose disorders of balance could be caused by a progressive demyelination of vestibulospinal system nerve fibers, VEMPs recording represents a meaningful method to spot new lesions in the brainstem, to assess the extent of the vestibular damage, and to monitor the evolution of the disease [10-12].
We recorded VEMPs from 29 patients enrolled from the Multiple Sclerosis Department of the Don Gnocchi Foundation, Milan, Italy.
The presence of external or middle-ear diseases that could interfere with the results had been ruled out in all subjects before the test. Because the amplitude of the response is influenced by the level of SCM contraction, which varies markedly between subjects, we mostly considered the latencies of the peaks, which are more stable and best suited to reflect the integrity of the vestibulospinal system pathway. In definite MS patients, we found VEMPs to be abnormal in 14, absent (on the left side only) in 1, and normal in the remaining 4.
VEMPS recording undoubtedly represents a simple method to investigate vestibulospinal pathways integrity [13-15]. Prolonged latencies have been recorded in both groups, whereas asymmetry of right-left responses is more frequent in definite MS cases. Previous studies [1,15-17] have shown good correlation in definite MS patients between VEMPs abnormalities and brainstem or cerebellar lesions; VEMPs were able to detect brainstem dysfunction in cases with normal nuclear magnetic resonance (NMR). Conversely, when demyelination of the vestibulospinal nerve fibers proceeds during the course of the disease, new lesions are produced.
On the basis of our experience, VEMPs recording may be considered a useful test for evaluating the function of the vestibulospinal pathways, both for detecting subclinical brainstem lesions in suspected MS patients and for monitoring the evolution of the disease.
The inner ear (auris interna) is the innermost part of the human ear, which also comprises the outer ear (auris externa) and the middle ear (auris media). At the time of birth, every human being with full auditory capabilities disposes of approximately 3,500 inner hair cells, 13,000 outer hair cells and 30,000 neurons per cochlea. Audiovestibular symptoms are the first and often the only clinical signs of vertebrobasilar insufficiency. Audiovestibular symptoms are the first and often the only clinical signs of vertebrobasilar insufficiency (VBI). Anatomical and physiological investigations of blood supply of the vestibular analyzer and vestibular receptors show that these structures are found in most dysfunctional circulatory situations, as anastomotic links are absent and ischemic damage is possible [5-8]. Above-threshold vestibular provocation was registered by ENG, and asymmetrical reactions for duration, amplitude, frequency, and establishment of the slow-phase speed (SPS) were evaluated, assuming as asymmetry differences of more than 20% between the two labyrinths.
Evaluation of the ENG according to duration (in seconds) is made by stop-stimulation until nystagmus strokes having an amplitude of 2 mm are registered or until the direction of nystagmus converts.
Caloric tests (for examining each labyrinthine irritation) are conducted 10 minutes after the rotatory tests, as the received nystagmus reactions are registered by the ENG at the same calibration as in the rotatory provocations. On ENG registration, the curve of spontaneous nystagmus shows that the relative share of people with spontaneous nystagmus increases in accordance with increasing age: Among the primary group of patients 40-49 years old, 30% (3 of 10 men) exhibited nystagmus, whereas in the 50- to 59-year-old group, 72% (18 of 25 men) demonstrated nystagmus.

The presence of spontaneous nystagmus noted on ENG recordings in patients in the primary group who had no vertigo complaints, however, indicates blood pressure dimensions leading to vestibular dysfunction. In caloric tests, in contrast to rotatory tests, only one labyrinth in each subject was examined. It is the opinion of many authors that directional nystagmus is a symptom of vestibular sys~m disturbance and is a sign of this system's central damage. The aforementioned, previously observed asymmetry indices-especially the SPS, duration, and amplitude indices of subjects in the primary group-showed statistically based increases relative to increasing subject age.
In caloric tests and rotatory investigations, important differences between the two groups were observed at an SPS asymmetry of more than 20% and frequent asymmetry of more than 20% at culmination.
In comparing the results of CP and DP asymmetry, we found that CP asymmetry is predominant at all indices, as the most important differences are determined in SPS asymmetry. If you are putting into a ballewick to be used as a natural antibiotic then don't use anything but about 40 drops per cup and no a lot more than 3 x each day. By eliminating certain foods or substances from your diet you may well be capable to reduce or even eliminate tinnitus from the life. It is extremely nice to see the greatest details presented in an easy and understanding manner. This section is visible on every page of your website. The sidebar is a great place to put important information like contact details, store hours, or social media links. In order to keep the feeling of balance, our vestibular system works with other sensorimotor systems in the body, such as our visual system (eyes) and skeletal system (bones and joints). This sophisticated system is constantly correcting itself in order to maintain balance, and these corrections are happening at all times throughout all your movements. In order to determine what the underlying cause of dizziness is, it is important to have a full diagnostic work-up to pinpoint where treatment should occur. This entry was posted in Balance and tagged balance, balance awareness week, dizziness, vestibular system.
Effects of Betahistine on Patient-Reported Outcomes in Routine Practice in Patients with Vestibular Vertigo and Appraisal of Tolerability: Experience in the OSVaLD Study. In order to obtain a wider perspective on this matter, we undertook an observational study to gather patientreported outcome information about dizziness, generic HRQoL and symptoms of anxiety and depression in a diverse population of patients suffering from peripheral vestibular vertigo.
The only exclusion condition was the presence of contraindications to betahistine, as identified in the relevant summary of product characteristics.
These visits were to be incorporated into the treating physician's usual pattern of follow-up consultations. The efficacy population of this study was defined as all patients allocated to treatment who (a) received a prescription of betahistine at baseline and who had at least one subsequent clinic visit (follow-up, final or endpoint visit) and (b) had a score calculated for at least one of the three specified outcomes scales (DHI total, SF-36v2 [both summary scores] or HADS [both anxiety and depression scales]) at the baseline visit and at least one post-baseline visit. If fewer than 50% of items were completed, the subscale and scale scores were not calculated.
Changes from baseline for all efficacy parameters were presented by descriptive statistics, including 95% confidence intervals and one-sample t-test.
Pearson correlation analyses were undertaken to explore the associations between the different efficacy variables. These events were also described according to their severity and their relationship to the study drug as judged by the investigator. Based on previous observations on the use of the DHI to evaluate drug therapy in patients with recurrent vestibular vertigo and published evidence that a difference in the total DHI score of 14 points is indicative of a clinically meaningful effect2,5, and allowing for 25% premature departure from the study, a recruitment target was set of 200 patients per country. Patients were advised that they were free to withdraw from the study at any time, for any reason and without offering any explanation for their decision, and that any such withdrawal could be made without prejudicing normal standards of clinical care.
Demographic data for these populations are presented in Table 1 and affirm that the profiles of both populations are congruent with the previously published preliminary baseline data4. In accordance with the norm-based criteria outlined in the Methods section, both these scores were below the U.S. Forty-nine patients were reported as having experienced at least one ADR (one patient experienced an event at both betahistine dosages).
The majority of ADRs were characterized as mild (47 events in 33 patients) or moderate (28 events in 19 patients). Thirty-one of the gastrointestinal disorders events were considered possibly (24 events) or probably (7 events) related to use of study medication, whereas 8 of the nervous system events were considered possibly (n = 7) or probably (n = 1) related.
These ADRs were predominantly gastrointestinal (11 events in 9 patients) or nervous system disorders (6 events in 6 patients).
Secondary analyses of results from individual participating countries may be expected to provide insights about the subjective circumstances of vertigo patients in a wider than usual range of national and cultural situations. Baseline data from OSVaLD provided corroboration of that premise, with consistent indications of diminished functional capacity and high prevalence of anxiety and depression at baseline4. Substantial improvements were registered in this measure, with a 37-point reduction in the mean total score and double-digit reductions in the three domains (physical, emotional and functional) of the DHI. Comparison of DHI improvements in OSVaLD with published data from other clinical trials of betahistine. These values are relatively high compared with data from various other types of illness21-23 and may be indicative of the impact of vertigo on HRQoL. Additional analysis of the trial database will be needed to establish whether and how the use of multiple instruments provided information beyond what may be obtained from individual questionnaires.
These numerous demonstrations of interrelations between different instruments lend credibility to - but cannot prove - the likelihood of a causal relation between the use of betahistine and the response of the various efficacy measures. Assessments were conducted in accordance with practitioners' standard clinical practice and the requirements of a PMS study. Albera R, Ciuffolotti R, Di Cicco M, De Benedittis G, Grazioli I, Melzi G, Mira E, Pallestrini E, Passali D, Serra A, Vicini C. Michopoulos I, Douzenis A, Kalkavoura C, Christodoulou C, Michalopoulou P, Kalemi G, Fineti K, Patapis P, Protopapas K, Lykouras L.
Two cases of bilateral vestibular loss, diagnosed by classical neurootological methods (highlighted by caloric and optokinetic tests' electronystagmography recording), are reported. A total of 25 acceleration steps are applied for each clockwise (CW) and counterclockwise (CCW) rotations. The patient was not able to perform more than 30 steps during Unterberger test (normal=100) and to keep standing more than 27 seconds (normal=60 sec.) in Romberg test.
3A and 3B) However, very small and hardly detectable responses with latencies of about 330 msec. His neurootological complaints were subjective bilateral tinnitus of Tinnitus cranii sive cerebri type, and a sudden aggravation of the bilateral high frequency hearing loss. Case 2 - CCO recording: pathological right deviation in the stepping test (mirrored image).
7 A and B show, VestEP elicited by either CWor CCW-rotations are markedly pathological: abnormal configuration of the waves, low voltage amplitudes.
Bilateral affection ofthe peripheral acoustical organs and probably of the brain stem acoustical pathways. The potentials were better detectable in all the examined derivations; the waves had higher amplitudes and significantly better morphologies.
The sine qua non condition for the generation of normal Vestibular Evoked Potentials is the morpho-functional integrity of the vestibular system, including receptors, brain stem pathways and cortical centers. Claussen C-F, Schneider D, Marcondes LG, Patil N: A Computer Analysis of Typical CCG Patterns in 1021 Neurootological Patients. Kolchev Ch, Claussen C-F, Schneider D, Constantinescu L, Carducci F, Sandris W: Extended Normative Data on VestEP displayed by BEAM. Kolchev Ch, Claussen C-F, Schneider D: Vestibular Evoked Potentials in Central Vertigo Cases. Claussen C-F, Schneider D, Kolchev Ch: On the functional State of Central Vestibular Structures in Monaural Symptomatic Tinnitus Patients.
Vestibular evoked myogenic potential (VEMP) estimates of the vestibular pathway that can not be analyzed by the other entrance examinations, which can be helpful in diagnosing the extent of hearing damage in these patients. However, the current trend is to consider the sudden hearing loss as a disease of multifactorial etiology1. The eliciting stimulus can be audible (click) or galvanic, activating the saccular macula and triggering the reflex pathway lowest labial nerve, lateral vestibular nucleus, spinal tract hall and finally ipsilateral motor neuron, being picked up by surface electrodes arranged on the sternocleidomastoid muscle7,8.
Despite this, few studies have been published focusing on the Vestibular Evoked Myogenic Potential in inner ear disorders such as sudden deafness10.
Of these, 67% found a positive relationship between the presence of VEMP and the degree of hearing recovery10,13,15,19,20,23.
The authors suggest that the sacculus is most often struck in the case of the PANSS the horizontal semicircular canal function and its afferent.
VEMP and ABR were positively correlated with a better prognosis, reaching 64% of full recovery in patients with hearing severe hearing loss20. The authors conclude that this is a useful method, however, point out that should only be used if the therapy used is the same adopted in the study25.
Among patients with recurrent ipsilaterally PANSS, all had normal VEMP and had hearing recovery. Professor e Orientador do Programa de Pos Graduacao em Ciencias da Saude da Universidade de Brasilia (UnB-DF). Fonoaudiologa do Governo do Distrito Federal (GDF), Mestre em Ciencias da Saude (UnB-DF) e Doutoranda em Ciencias da Saude (UnB-DF). Vestibular Evoked Myogenic Potentials in Multiple Sclerosis: A Comparison Between Onset and Definite Cases. The vestibulospinal reflexes in these subjects can be well investigated through vestibular evoked myogenic potentials (VEMPs).
Healthy subjects produce a biphasic response from the SCM characterized by a positive peak at a latency of some 13 msec (PI) from the stimulus followed by a negative wave peaking some 10 msec later (N2; Fig. To date, no study has yet investigated different VEMPs involvement at different stages of MS. We requested that each patient be seated on a comfortable chair and keep the head rotated to the side opposite the stimulated ear to activate the SCM. In the onset cases, we found VEMPs to be abnormal in 6, presenting bilateral increase of latencies in 3 and having significant right-left asymmetry in the remaining 3 (Fig.
Results of vestibular evoked myogenic potentials (VEMPs) recordings comparing alterations in onset multiple sclerosis (MS) and definite MS patients.
In fact, it provides rapid, useful information about vestibular and vestibulospinal reflex function.
In the same way, in general, VEMPs are more frequently compromised in definite MS cases than in onset cases.
In this group of onset MS cases, VEMPs were altered in 6 with normal NMR findings, and neuroimaging was altered in 2 with normal VEMPs.
Prolonged peak latencies are also found in the early stages of the disease when other diseases mimicking MS must be ruled out [17]. It comprises the snail shaped cochlea (from Greek: kochlias = snail), which is our organ of hearing, and the vestibular system, which is our our organ of balance. Its function is to convert sound energy into neural signals which are carried to the brain.
Damage or loss of hair cells, neurons, nerve fibers or other structures in the cochlea from injury or other sources (e.g.
Electronystagmographic and Caloric Investigation Data About V ascular-Vestibular Dysfunction Among Patients with Vertebrobasilar Insufficiency. The aim of our investigation was to analyze the results of caloric and electronystagmographic investigation of vascular-vestibular disorders among patients with vertebrobasilar insufficiency.
The complicated perception of position of the body and its parts in space is a result of analyzed and synthesized impulses by the vestibular analyzer, by superficial and deep proprioception, and by the ocular analyzer, as the vestibular receptors play the main part in this system [1-4]. With the exception of arterial hypertonia or atherosclerosis (or both), pathological changes in the cervical spine (cervical osteoporosis) may lead to disturbances in blood supply of the labyrinth and brainstem. All examined patients were divided into two groups according to their age: 40-49 years and 50-59 years. The average amplitude (in degrees) and frequency (in Hertz) have been calculated at a definite part of the ENG, wherein the nystagmus strokes are maximally expressive, coinciding according to time and distance in the left and right labyrinth.
Among the control group, 0% of 40- to 49-year-olds and 10% of 50- to 59-year-olds (l of 10 men) were found to have nystagmus. As a whole, the reactions show hyporeflection, which correlates with the data of rotatory tests. In comparing the results of CP and DP asymmetry, we found that CP asymmetry is predominant in all groups at all indices, as the most significant differences -are determined in SPS asymmetry.
The differences between the two examined groupssubjects and controls-are statistically important for indices of more than 25% asymmetry, relative to the exaggerated vascular disorders in the vertebrobasilar system and especially in the a.
As regards DP results, the most important index was SPS asymmetry (DP) of more than 20%, followed by frequent asymmetry. In both rotatory and caloric tests, this index was shown to provide the most information about functions of the vestibular analyzer. The sound differs for each person and may be static, ringing, hissing or some other form of noise. His experience of loud noises throughout his life included hunting, playing the drums and attending earsplitting concerts. How the GSE works would it be kills the bacteria that produces acne because GSE is a brand natural bacterial fighter along with an antibiotic.
The vestibular system also helps us maintain a steady focus on objects even though the position of our body changes. To see the vestibular system in action visit this great tutorial on the site about kids health.
It is a way of letting you know something within your body is out of sync and can be an indicator of a variety of health disorders. Study endpoints comprised on-treatment changes in the Dizziness Handicap Index (DHI), Hospital Anxiety and Depression Score (HADS) and the Short-Form (SF)-36v2. For each question, a "Yes" response scored four points, a "No" response scored zero points and a "Sometimes" response scored two points.
The same categories were applied to both subscale scores: 0-7 points = normal, 8-10 points = mild, 11-14 points = moderate and 15-21 points = severe. Most of these events were recorded in participants in Brazil (10 events in 7 patients) or Slovenia (9 events in 6 patients).

The primary results of OSVaLD, reported here, add to experience with HRQoL instruments in vertigo and provide original data on the response of those indices to therapy delivered in the context of routine clinical care. The improvement in the total DHI score considerably exceeded the numerical threshold for a clinically meaningful response. The possible contribution of non-vertigo factors to these scores must be acknowledged, although in the sphere of neurological conditions, differentiating cause and effect can be especially difficult24,25. An extensive series of correlations has already been identified between responses in the DHI, HADS and SF-36v2 (Table 3). This qualification may be especially relevant to depression, which is often the product of multiple influences and likely to be beyond the scope of a single medical intervention.
A 3-month follow-up was chosen as a length of time sufficient to generate useful safety and tolerability data. Fixed combination of cinnarizine and dimenhydrinate versus betahistine dimesylate in the treatment of Meniere's disease: a randomized, double-blind, parallel group clinical study.
Double-blind, randomized, multicenter study comparing the effect of betahistine and flunarizine on the dizziness handicap in patients with recurrent vestibular vertigo. Patient baseline characteristics in a multinational study of betahistine in recurrent peripheral vestibular vertigo: the OSVaLD study.
Evaluation of health-related quality of life in individuals with vestibular disease using disease-specific and general outcome measures. Test of reliability of the dizziness handicap inventory and the activities-specific balance confidence scale for use in Sweden. Reliability of clinical balance tests and subjective ratings in dizziness and disequilibrium. Long-term outcome and health-related quality of life in benign paroxysmal positional vertigo.
Impact of treatment on health-related quality of life in patients with posterior canal benign paroxysmal positional vertigo. Health-related quality of life in patients over sixty years old with benign paroxysmal positional vertigo.
Hospital Anxiety and Depression Scale (HADS): validation in a Greek general hospital sample. Assessment of the structure of the Hospital Anxiety and Depression Scale in musculoskeletal patients.
Antidepressant treatment of chronic tension-type headache: a comparison between fluoxetine and desipramine. Correlated physical and mental health summary scores for the SF-36 and SF-12 Health Survey, V.I.
Benign paroxysmal positional vertigo: a study of two manoeuvres with and without betahistine.
Division of Otoneurology, Department of Otorhinolaryngology, Hospital Universitario La Fe, Passeig de la Sequia 12, 46111 Rocafort, Valencia, Spain. Department of Otolaryngology-Head and Neck, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian 16150, Kelantan, Malaysia.
Solvay Pharmaceuticals BV, Postbus 900, CJ van Houtenlaan 36, Weesp, NL-1380 DA, The Netherlands. The additional information, provided by the Vestibular Evoked Potentials (VestEP) and its high clinical significance for a more accurate neurootologic diagnosis are discussed. The history of his disease began in 1963, with the diagnosis of a complete cochleovestibular loss left, due to a Jaffe-Lichtenstein Syndrome (fibrose bone dystrophy with secondary cysts formation at left petrous bone, mastoid process, and occipital squama). The severity of these complaints was relatively mild at onset in 1989, but then it increased progressively.
The latencies of the main components, and especially of wave III are normal in CW-rotation, but significantly shortened (25 msec.) in CCW-rotation. We found extremely interesting the manner in which the complete absence of the vestibular function, as well as the very severe affection of the auditory function, were compensated by the visual and proprioceptive functions, the patient being able to lead a relatively normal life, with a satisfactory degree of social independency. This case is more complex and thanks to the information supplied by the VestEP-BEAM method, we could make some suppositions about the location and the mechanisms of the neurootological disorders and recommend a correct therapy. Currently its route and method are well defined and the latter studies devoted to clinical applications9. Of these, 15 articles were included in the study by fitting either the inclusion factors (Table 2). Others studies despite having different objectives pointed VEMP as helpful tool in the management of patients with sudden sensorineural hearing loss17,18,21,22,25. They add that the creation of the VEMP associated with caloric test is useful in the evaluation of these patients as they relate to the degree of hearing recovery23. Since patients with contralateral applicant PANSS, 80% had altered VEMP, showing no hearing recovery after treatment. Ocular vestibular evoked myogenic potentials induced by bone-conducted vibration in patients with unilateral inner ear disease.
Subjective visual vertical perception in patients with vestibular neuritis and sudden sensorineural hearing loss. Distortion product otoacoustic emissions as a prognostic factor for idiopathic sudden sensorineural hearing loss. Saccular damage in patients with idiopathic sudden sensorineural hearing loss without vertigo.
Three-dimensional fluid-attenuated inversion recovery magnetic resonance imaging in sudden sensorineural hearing loss: correlations with audiologic and vestibular testing.
Correlation between audiovestibular function tests and hearing outcomes in severe to profound sudden sensorineural hearing loss. Difference in the nature of dizziness between vestibular neuritis and sudden sensorineural hearing loss with vertigo. Abnormal vestibular evoked myogenic potentials in the presence of normal caloric responses. Extent of lesions in idiopathic sudden hearing loss with vertigo: study using click and galvanic vestibular evoked myogenic potentials. Evoked by the acoustic stimulation of the saccular macula and mediated by the vestibulocollic reflex pathway, they are recorded using surface electromyographic electrodes from the ipsilateral sternocleidomastoid muscle tonically contracted.
Many times, vestibulospinal reflexes are involved, and vestibular evoked myogenic potentials (VEMPs) are specific for documenting vestibulocollic involvement in MS patients [1]. Normal morphology and latencies are seen on the left side (A), whereas increased latencies and decreased amplitude are seen on the right side (B). We placed the active surface electromyogram electrode on the SCM of the stimulated side and referred it to the ipsilateral clavicle, whereas a ground electrode was fixed on the upper sternum. We performed four repetitions on each side and made no adjustment for individual hearing loss.
Prolonged latencies have been recorded in both groups; asymmetry of right-left responses is more frequent in definite MS cases. In addition, the test can be very important in MS patients, because they frequently suffer from equilibrium disorders related to vestibulospinal system involvement. Prolonged P1 or N2 latencies, abnormalities of the interpeak latencies, and a total absence of the response suggest the presence of lesions in the vestibulocollic pathway, probably arising from a progressive demyelination of the nerve fibers.
Latencies of vestibulospinal reflexes can be prolonged, and sometimes the response can be absent, depending on the degree of the nervous transmission dysfunction, a degree that seems to be correlated with the stage of disease. Vestibular evoked myogenic potentials in multiple sclerosis: Clinical and imaging correlations. Vestibular-evoked myogenic potentials: A method to assess vestibulo-spinal conduction in multiple sclerosis patients. According to various authors [2,3,5,9-14], chronic irritation of the sympathetic nerve plexus around the vertebral and basilar arteries provokes reflex changes in blood supply of the inner ear, which leads to vertigo, noise in the ears, and a feeling of hearing loss. The signal is valid for the following parameters: a lO-mm graphic view of the fast site of the nystagmus in a 10-degree angle diversity of the eyes, for left or right to center. Therefore, this index must be applied in routine neurootological practice, especially in vascularvestibular disorders. The results of that objective investigation show that receptor damages of the vestibular analyzer prevail over the central ones in people with vascular-vestibular dysfunction at ages between 40 and 49 years.
This is accomplished by mechanical forces, such as gravity, acting upon our vestibular organs as we move. Total DHI score improved 37.2 points (of a 100-point scale) following betahistine treatment.
Statistical analysis was performed using SAS version 8.2 and SF Health OutcomesTM Scoring Software of Quality Metric Incorporated. The baseline SF-36v2 data for the OSVaLD population would also appear to support the view that this was a group with a low HRQoL26.
The observed reduction in HADS-assessed depression severity and distribution seen in this study is perhaps the more noteworthy for that reason. Issues of differential diagnosis were considered in an earlier report4; there is currently no reason to think that our database has been affected by major variations in, or errors of, diagnosis. Psychometric and clinical tests of validity in measuring physical and mental health constructs. Jaffe-Lichtenstein Syndrome affecting left petrous bone, mastoid process, and occipital squama: A. Since 1985, the patient also complained of sinoatrial bradycardia and tendency to low blood pressure. 10A and B) There was also a tendency to normalization of the latencies, especially of the wave III, in the CCW-rotation (15 msec.
The more severe and extended the lesions are, the more disturbed will be the recorded VestEP. Thus, the results of the complete neurootological examination demonstrate that both the acoustic and vestibular systems are affected by the pathological process. It was concluded that VEMP can be used as a prognostic factor in recurrent PANSS in order that their presence would indicate a high probability of hearing recovery19. These authors revealed that the evoked response was probably generated by reflex changes in the electromyogram of posterior neck muscles and that it was present in patients with sensorineural deafness, leading the researchers to propose that it arose from the sound-evoked activation of the vestibular apparatus ("Tullio phenomenon") [3]. Abnormal results, ranging from prolonged latencies to total absence of the response, disclose lesions anywhere in the VCR pathway [8,9].
We presented a continuous noise of 70 dB to the contralateral ear and performed recordings using a standard clinical evoked potential averager (Nicolet CA2000, Clackamas, USA) with time bases of 50 msec. In the same way, in general, vestibular evoked myogenic potentials are more frequently compromised in definite cases than in onset cases. The main limitations of the test are lack of patient cooperation, presence of neck stiffness, inability of patients to keep the SCM tonically contracted for a few seconds, and the presence of external or middle-ear diseases (chronic otitis, otosclerosis). A delay of VEMPs can be attributed to demyelination either of primary afferent axons at the root entry zone or of secondary vestibulospinal tract axons, rather than to lesions of vestibular nucleus neurons. This motion is sensed by the stereocilia of hair cells and transduced by inner hair cells via neurotransmitters, primarily glutamate, into excitation of the auditory nerve. Such cochlear dysfunction may manifest itself through symptoms such as hearing loss, sound intolerance, or tinnitus. Standard and electronystagmographic ("Tonnies" type) caloric tests were used to evaluate the human vestibular analyzer.
Our aim in this investigation was to analyze the results of caloric and electronystagmographic (ENG) investigation of vascular-vestibular disorders among patients with VBI. The results obtained by lonkins and Philipson's formula [4] for prevalence in relation to the direction (DP), at the same indices (Fig. Within the total score, individual scores were generated for the three subscales "physical" (seven questions), "emotional" (nine questions) and "functional" (nine questions). The effects of betahistine on these indices of HRQoL should be considered in this context of marked baseline HRQoL deficits. Correlations between the DHI and SF-36v2 domains have been reported previously18, but we believe this to be the first demonstration of correlations between the HADS and DHI in a large-scale vertigo study.
The original objective of recruiting 200 patients per country was not achieved, but the statistical findings remain robust and the trend of responses was consistent in all countries, suggesting that the efficacy findings are a reliable indication of a true effect.
The most active areas (dark yellow), corresponding to the suspected electrical events with latencies of about 330 msec., have a frontal distribution.
Subsequent publications by Cody and Bickford [4] described the inion response in subjects suffering from different cochlear and vestibular syndromes and provided further evidence to suggest that it depended on the activation of the saccular macula. We also twice averaged the responses to both series of sweeps, to produce one grand average for each side and for each subject.
Our data from this investigation show that in both rotatory and caloric tests, the slow-phase speed is the most important index about function of the vestibular analyzer. Further it can be demonstrated that the effect seen in OSVaLD on the DHI was similar to that seen in double-blind, placebo controlled clinical studies with betahistine (Figure 4). Therefore we can speak about a combined acoustic and vestibular, peripheral and central neurootological syndrome. VEMPs in definite MS subjects were abnormal in 14, absent (on the left side only) in 1, and normal in the remaining 4. Those authors concluded that VEMPs recording depended on the activation of a specific reflex function called the vestibulocollic reflex (VCR), mediated by a pathway consisting of the saccular macula, its primary neurons, vestibulospinal neurons from the lateral vestibular nucleus, the medial vestibulospinal tract and, finally, the motor neurons of the spinal cord reaching neck muscles [5]. It most likely reflects a vascular insufficiency within the vertebro-basilar system due to possible micro-tromboembolization, rheological changes, dynamic circulatory insufficiency, more pronounced on the left side. Sensory cochlear hair cells and vestibular receptors are especially affected by hypoxia, due to the terminal type of arterial circulation of the labyrinth. These results suggest that latencies of vestibulospinal reflexes can be remarkably delayed in MS at different stages of disease, whereas vestibulospinal involvement is more frequent in definite cases.
These suppositions are also stressed by the positive effect of the treatment with betahistine.

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