Otology & Neurotology 32:812Y817 Ó 2011, Otology & Neurotology, Inc.

Bilateral Vestibulopathy: Clinical Characteristics and Diagnostic Criteria
*†Seonhye Kim, *Young-Mi Oh, ‡Ja-Won Koo, and *Ji Soo Kim
*Department of Neurology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Gyeonggi-do; ÞDepartment of Neurology, Pusan National University School of Medicine, Pusan National University Yangsan Hospital, Yangsan; and þDepartment of Otolaryngology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Gyeonggi-do, Korea

Objectives: To define clinical and laboratory characteristics of bilateral vestibulopathy (BV) and to propose diagnostic criteria of this disorder based on clinical and laboratory findings. Study Design: Retrospective case series review. Materials and Methods: We recruited 108 patients with a clinical suspicion of BV based on presenting symptoms (unsteadiness or oscillopsia during locomotion) and bedside (dynamic visual acuity or head impulse tests) and laboratory (bithermal caloric or rotatory chair tests) findings after excluding the patients with other disorders that may explain the symptoms. Definite diagnosis of BV was made when the patients showed abnormal findings on both bedside and laboratory tests in addition to the symptoms, whereas probable diagnosis was obtained when either the bedside or laboratory findings were abnormal along with the symptoms. Results: All patients had unsteadiness, and 36 (33%) reported oscillopsia. Diminished vestibulo-ocular responses to head im-

pulse in both horizontal directions were present in 45 of the 100 patients evaluated. Dynamic visual acuity was impaired in 65 (95%) of the 68 patients who underwent testing. Fifty-one (57%) patients showed bilateral hyporesponsiveness during bithermal caloric tests. Forty-eight (53%) patients had reduced gain of the vestibulo-ocular reflex during rotatory chair test. By adopting our diagnostic criteria, 93 patients (86%) were diagnosed as having BV, definite in 49 (45%), and probable in 44 (41%). Conclusion: The proposed diagnostic criteria encompass the symptoms and findings of both bedside and laboratory evaluations and may provide a valuable tool for investigating BV. Key Words: Bilateral vestibulopathyVOscillopsiaV UnsteadinessVVertigoVVestibulo-ocular reflex. Otol Neurotol 32:812Y817, 2011.

Bilateral vestibulopathy (BV) is characterized by oscillopsia and unsteadiness, mostly during locomotion (1Y5). Although various diagnostic tools have been proposed, BV remains a diagnostic challenge because each diagnostic test has its own limitation without unified diagnostic criteria. For example, absent or reduced responses during bithermal caloric stimulation have been

Address correspondence and reprint requests to Ji Soo Kim, M.D., Ph.D., Department of Neurology, College of Medicine, Seoul National University, Seoul National University Bundang Hospital, 300 Gumi-dong, Bundang-gu, Seongnam-si, Gyeonggi-do, 463-707, Korea; E-mail: jisookim@ snu.ac.kr The statistical analyses were conducted by Seonhye Kim, MD, Department of Neurology, Seoul National University Bundang Hospital, in consultation with Medical Research Collaborating Center Seoul National University Hospital. This study was supported by a grant from the Korea Health 21 R&D Project, Ministry of Health & Welfare, Republic of Korea (A080750). The authors report no disclosure.

adopted as a diagnostic criterion of BV (6Y8). However, because caloric stimulation corresponds to a sinusoidal stimulus frequency of 0.003 Hz and does not reflect natural rotational frequency of the head during locomotion (8,9), bilateral absence of caloric responses does not necessarily indicate a complete absence of the vestibular function (10). Reduced gain, increased phase lead, and shortened time constants of the vestibulo-ocular reflex (VOR) in response to low-frequency rotation are characteristic of BV (11Y14). However, the highest rotational frequency achievable is less than 1.0 Hz in most equipment commercially available for human study (15). A few studies embraced clinical symptoms and bedside neurologic examinations, such as head impulse (HIT) or dynamic visual acuity (DVA) test, for diagnosis of BV (7,16Y20). HIT is useful in detecting vestibular hypofunction in BV (21). However, covert saccades may conceal BV even in patients with total vestibular loss (21). DVA has been used as an indirect indicator for 812

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We reviewed the medical records of the patients and performed an additional telephone interview in 64 patients whose medical records did not include sufficient information on the symptoms and possible causes of vestibulopathy. including HIT. the patient was again subjected to measurement of visual acuity. and the test result is not better than a chance. Nevertheless. DVA test can display false-negative results when other mechanisms compensate for the retinal instability during head movements (7). We especially excluded the patients with unsteadiness or oscillopsia because of cerebellar disorders without bilateral vestibular failure. Results of laboratory tests (either A or B) A. vestibular paroxysmia. Other causes excluded Definite diagnosis: met all 4 diagnostic criteria. Statistical Analyses We used t test to compare the continuous variable (age) and W2 test for dichotomous variable (sex) between the groups.7. Otology & Neurotology. USA). Vol. we plotted receiver operating characteristic (ROC) curves with true positives on the vertical axis (sensitivity) and false positives on the horizontal axis (1-specificity). S. Dynamic Visual Acuity Test DVA was measured with a Rosenbaum card which was held 14 inches from the eyes. 32. Unauthorized reproduction of this article is prohibited. Copyright © 2011 Otology & Neurotology. Inc. BV was defined by summated slow phase velocity (SPV) of the nystagmus of less than 20 degrees per second during 4 stimulation conditions. All tests were performed using SPSS (version 15. Reduced responses (summated slow phase velocity of the nystagmus G20 degrees per second) during bithermal caloric tests B. However. 813 USA). S.19.10. Criteria 1. orthostatic hypotension. Instead. SPSS. and laboratory tests in diagnosing BV. no study has attempted to incorporate all these clinical symptoms. unsteadiness or oscillopsia during locomotion). IL.04 Hz and summated SPV during bithermal caloric tests. To evaluate sensitivity and specificity of each diagnostic criteria. DVA was measured only in 68 (63%) patients because it was applied only by a neurologist (J. Oscillopsia Criteria 2. and unilateral vestibular loss (16).6. Reference visual acuity was determined during head stabilization. No. Proposed diagnostic criteria for bilateral vestibulopathy Bithermal Caloric Tests The caloric stimuli comprised alternate irrigation for 25 seconds with 50 ml of cold and hot water (30-C and 44-C) (25). Selection of these criteria was based on similarities of the testing methods for bithermal caloric and rotatory chair tests. ICS Medical. Loss of 3 or more lines as compared with the reference level was considered abnormal (1). Dallas.27). Evaluation of Diagnostic Properties We also compared the diagnostic yield of our criteria with those reported previously (2.. Most patients underwent evaluation of the vestibular function. Detailed methods and normative data were described elsewhere (26). The area under the curve is a quantitative measure of the test capacity. Spearman’s correlation also was used to compare the VOR gain during rotation at 0. W. Definite diagnosis of BV was made when the patients met all 4 diagnostic criteria. results of bedside evaluation (Criteria 2. Diagnostic Criteria of BV We proposed our own diagnostic criteria for BV. 2011 Rotatory Chair Test Rotatory chair test were performed in darkness using a rotatory chair system (CHARTR. In this study. Positive head impulse test in both horizontal directions B. visual disorders. K.23). Symptoms only during locomotion (either A or B) A. whereas the head was oscillated approximately at 2. MATERIALS AND METHODS Subjects At the Dizziness Clinic of Seoul National University Bundang Hospital. USA). Table 1).05 was considered significant. Head Impulse Test HIT was performed manually with rapid rotation of the head of approximately 20-degree amplitude in the yaw plane.5 Hz in the horizontal plane with estimated amplitudes of 10 degrees. hyperventilation syndromes. Impaired dynamic visual acuity Criteria 3. and absence of other causes (Criteria 4. After then. we propose diagnostic criteria of BV that incorporate both clinical and laboratory findings.). bithermal caloric or rotatory chair tests). intoxication. TX. Nystagmus was recorded binocularly using video-oculography (NCI-480. K.25). The area under the curve value of 0. Reduced vestibulo-ocular reflex gain during rotatory chair test Criteria 4. we estimated the sensitivity and specificity of the previously adopted diagnostic criteria (Models 2Y6) using our own criteria as a reference standard. perilymph fistula. 5. ICS Medical. . DVA may be a better measure of functional vestibular impairments and can be easily performed (24). diagnosis of BV should be based on comprehensive evaluation of the vestibular function using both clinical and laboratory findings. 108 consecutive patients with unsteadiness or oscillopsia only during locomotion had been recruited from May 2003 to February 2007. HIT was considered abnormal if an obvious corrective saccade supplemented the inadequate slow phase in both directions (21. HIT or DVA) and laboratory tests (Criteria 3.). and p G 0. However. IL. Probable diagnosis: met the criteria 2 or 3 in addition to Criteria 1 and 4. Chicago. bedside examination.18. we were unable to plot the ROC curves for our diagnostic criteria. which incorporated symptoms (Criteria 1. Unsteadiness B. Findings of bedside evaluations (either A or B) A. TABLE 1. bithermal caloric. Schaumburg. and rotatory chair tests in addition to routine neurologic and otologic examinations by the authors (J. and J. whereas probable diagnosis was obtained when the patients experienced the symptoms (Criteria 1) without other identifiable causes (Criteria 4) and exhibited abnormal results during either the bedside (Criteria 2) or laboratory tests (Criteria 3). Because confirmatory tests are not available for BV. Accordingly. Inc. phobic postural vertigo.5 indicates that the true-positive rate equals the false-positive rate.BILATERAL VESTIBULOPATHY effectiveness of the VOR in stabilizing gaze during head rotation (22. K.

Fig.2 T 15. All of them showed reduced gain at lower (0.08.9 0. KIM ET AL.04 Hz with a peak velocity of 50 degrees per second (r = 0. Other clinical characteristics and causes were summarized in Table 2.814 RESULTS S.4 18Y88 65. Demographic and Clinical Characteristics Patients included 60 women and 48 men without difference in age between women and men (Table 2).3 T 16.4 T 16. 32. 0.2 52.670. Inc.16. 1. whereas 49 (45.3 12Y88 No.02 and 0. . Results of rotatory chair test were abnormal in 48 (53%) of 91 patients (Fig.8 19. 2).04 Hz) frequency rotations.4 11. There was no difference in age and sex between the idiopathic and secondary groups (Table 2).16. DVA was impaired in 65 (96%) of the 68 patients tested.4 12Y88 62. 1).7%) patients met the definite criteria of BV. r = 0.04 Hz) frequency rotations. FIG.1 3.05 61. The summated SPV of the nystagmus induced during bithermal caloric stimuli showed a positive linear correlation with the VOR gain at 0.8 12Y88 90. and 45 of them showed corrective catch-up saccades in both directions.04 Hz during rotatory stimulation (Spearman’s correlation. Patients age Clinical characteristic and causes of bilateral vestibulopathy Mean T SD Range p value Evaluation of Diagnostic Properties According to our diagnostic criteria.05 63. Gains of the VOR in 48 patients that exhibited reduced gains during sinusoidal harmonic accelerations. and 0.001. and most of them (n = 42 [88%]) also showed abnormalities during higher (0. 5. Percentage (%) 108 100 36 33 30 28 20 19 13 12 51 57 21 12 4 4 1 1 14 (3) (2) (2) (3) (2) (2) 47.0 FIG.9 T 16.5 15Y86 90. Bithermal caloric tests showed reduced response in 51 (57%) of 89 patients.08. 44 (40.7 0. All the patients with abnormal rotatory responses exhibited reduced gain and increased phase leads during lower (0. whereas 17 patients exhibited positive results only unilaterally.001). and most of them (n = 42 [88%]) also exhibited diminished gain at higher (0.7 T 17. Otology & Neurotology.4%) had the diagnosis of probable BV (Table 3). Vol. Overall.32 Hz) frequency rotations (Fig. p G 0. T2 standard deviation) of the VOR gain at each frequency.02 and 0.9 13.670. 1). definite or probable diagnosis of BV could be Total (n = 108) Men (n = 48) Women (n = 60) Idiopathic group (M:W = 23:21) Secondary group (M:W = 37:27) Clinical symptoms Unsteadiness Oscillopsia Transient vertigo Bilateral hearing loss Tinnitus Causes Idiopathic Secondary Ototoxicity ´ nie ` re’s disease Bilateral Me Bilateral sequential vestibular neuritis Head trauma Bilateral chronic otitis media Autoimmune disorder Neurologic diseases Central nervous system infection Cerebellar infarction Cerebellar degeneration Superficial siderosis Tumor Neuropathy 62. Bedside and Laboratory Vestibular Function Tests Horizontal HIT was performed in 100 patients. including no response in 4 of them.32 Hz) frequency rotations. 0. The summated SPV of the nystagmus induced during bithermal caloric stimuli shows a positive linear correlation with the gain of the VOR during sinusoidal harmonic acceleration at 0. 2011 Copyright © 2011 Otology & Neurotology. p G 0. and 0. 2.7 3. Unauthorized reproduction of this article is prohibited. The gray box indicates reference ranges (mean. TABLE 2. No.

19.1) at low-frequency rotational chair test Model 6 (18. made using our criteria in 93 (86. Caloric test (reduced caloric responses G20 degrees per second) Definite (n = 44) or rotatory chair test (decreased gain at lower frequency stimulation: G0.525 0.27).37).6.4) Absent caloric response Model 3 (27) 51/87 (58. there has been no consensus on the range of responses (nystagmus) required for diagnosis of BV during caloric stimulation (1.7 13.2. 2011 Copyright © 2011 Otology & Neurotology. However. previous studies introduced ice-water stimulation in case of absent responses during bithermal caloric irrigation (6. the most common and most important complaints are unsteadiness and oscillopsia during locomotion. The unsteadiness typically worsens in darkness or on uneven surfaces (5.7 63.16). whereas the specificity was uniformly 100% (Table 3).2) HIT + absent or reduced caloric response (SPV. When applying the previously reported diagnostic criteria. we proposed diagnostic criteria of BV that incorporated clinical symptoms and results of both bedside examination and laboratory tests.4% to 58. Inc.1) 1.27. the degree of subjective complaints may not follow the severity of vestibular dysfunction measured using objective tests (1). However. 32. dynamic visual acuity.18. Using our criteria. bilateral vestibulopathy.BILATERAL VESTIBULOPATHY TABLE 3.7. head impulse test. Furthermore. absent responses during bithermal caloric stimulation does not necessarily indicate a complete loss of the vestibular function (33). Caloric and rotatory chair tests have been adopted in diagnosing BV (1. Bilateral pathologic HIT + reduced caloric response Incomplete (n = 43) (SPV. G5 degrees per second) h Complete: pathologic HIT + absence of caloric response h Incomplete. Model 815 Diagnostic accuracy of our own and previously proposed criteria for bilateral vestibulopathy Diagnosis of BV (%) Sensitivity (%)a Specificity (%)a AUC Model 1 93/108 (86. HIT.589 0.6) Reduced caloric response (G24 degrees per second) Model 4 (2) 4/77 (5. G10 degrees per second) +Decreased gain (0.1%) of 108 patients that experienced unsteadiness or oscillopsia only during locomotion without other identifiable disorders. . ice-water irrigation is unpleasant and painful and may produce pseudocaloric nystagmus by activating latent spontaneous nystagmus (35.6 17. Unsteadiness also occurs with high-frequency head movements because detection of high-frequency head rotation is a domain of the vestibular apparatus (28. DVA or HIT 3.14).38Y40).13. Impaired VOR may be compensated by other mechanisms (7. The sensitivity of the previous criteria ranged from 3.4. hindering the multisensory process of postural control (28). BV.13. DISCUSSION In this study.29). the oscillopsia also was described in only 25% to 50% of the patients with BV (1).16). Unsteadiness is a reflection of impaired vestibulo-spinal reflex.6.19) 46/79 (58.30Y32). Rotatory chair test adopts more physiologic stimuli over a broad frequency range and has been regarded a better method for identifying patients with BV (10. a Receiver operating characteristic curves were used to measure the sensitivities and specificities of the previously reported diagnostic criteria using our own criteria as reference standards.823 0.7.2) Absent or reduced caloric response (SPV.10. However. slow phase velocity. We also determined the sensitivity and specificity of the previously reported criteria using our criteria as a reference standard (2. No.2) Probable (n = 49) h Definite: 1 + 2 + 3 and other causes were excluded h Probable: 1 + either 2 or 3 when other causes were excluded Model 2 (6. All our patients experienced unsteadiness during locomotion. In the previous reports. Bilateral pathologic HIT + caloric responses 95 degrees per second on 1 or both sides 3.1 64. Unauthorized reproduction of this article is prohibited. G5 degrees per second) 2. SPV. we were able to diagnose BV in 86% of the patients with oscillopsia and unsteadiness only during locomotion after excluding the patients with other disorders that may explain the symptoms. Complete (n = 3) 1. To determine any vestibular function remained.0 100 100 100 100 100 0. In BV.586 0.0 to 64. Unsteadiness or oscillopsia 2. only 36 (33%) of them reported oscillopsia.0) Absent or reduced caloric response (SPV. However.6% of the patients that underwent the tests adopted in those criteria (Table 3). Oscillopsia also occurs in BV because of bilaterally impaired VOR that reduces stabilization of the images on the retina (retinal slip) during locomotion and head movements (1. In patients with vestibular disorders. G5 degrees per second) +Decreased gain at low-frequency rotatory chair test Model 5 (10) 10/77 (13.815 AUC indicates area under the curve. 5. diagnosis of BV could be made in 3.34). commercially available rotatory chairs for human study do not readily evaluate the VOR at frequencies above 1 Hz where the head usually oscillates Otology & Neurotology.6%. DVA.36).7) 3/87 (3. Normal HIT + absence or reduced caloric responses (G5 degrees per second) 5. Vol.

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