Speech, Language and Hearing

Masseteric Vestibular Evoked Myogenic Potential Click Vs. Toneburst Normative and
gender difference
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Manuscript Number:

Full Title: Masseteric Vestibular Evoked Myogenic Potential Click Vs. Toneburst Normative and
gender difference

Article Type: Original Research Paper

Keywords: Vestibular System; Vestibular Evoked Myogenic Potential (VEMP),Vestiblo trigeminal

pathway; Masseter Vestibular evoked myogenic Responses(mVEMP); Vestibulo-
masseteric reflex

Corresponding Author: Vishnuram B

SRM Medical College Hospital and Research Centre
INDIA

Corresponding Author Secondary

Information:

Corresponding Author's Institution: SRM Medical College Hospital and Research Centre

Corresponding Author's Secondary

Institution:

First Author: Vishnuram B

First Author Secondary Information:

Order of Authors: Vishnuram B

Aparna Ravichandran

R Hemavathy

Samathana prabu I

Hariprasanth S

Rajkumar s

Order of Authors Secondary Information:

Abstract: Background

Vestibular elicited myogenic potential (VEMP) is utilized in the diagnosing various

vestibular diseases. VEMP uses many stimulants to stimulate the sensory system and
measure myogenic potentials.

Purpose

of this study was to match the results of tone burst and click on stimulation and Gender
difference in mVEMP on the latency and amplitude of myogenic potentials.

Research Design

Cross-Sectional Design Experimental Research was used.
Methods and analysis

Study includes 40 volunteers with a total of 80 ears. The masseter muscle potential of
every ear following a 500-Hz tone burst and click stimulation is measured in a sitting
position and the latency and amplitude is evaluated.
Results
The tone burst stimulation
resulted in waves with longer latency (12.13 ± 0.81 ms) however higher amplitude
(48.53 ± 25.64 µV) compared with the different stimuli, and also the click stimulation
resulted in waves with shorter latency (11.45 ± 0.87 ms) however lower amplitude
(31.23±18.56 µV) (p<0.001). The mVEMP asymmetry ratio failed to significantly differ.
Female have shorter latencies (12.06 ± 0.79 ms) and also shorter amplitude (46.83 ±
18.69 µV) (p<0.005) than males. Asymmetric ratio was not significantly different

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 between each group.
Conclusion
Amplitudes and latencies of various stimuli and gender
were significantly differ, studies need more number of patients and stimulus varieties
are to get standardized mVEMP results.

Funding Information:

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1 Masseteric Vestibular Evoked Myogenic Potential Click Vs.

2 Toneburst Normative and gender difference

3 Aparna Ravichandran***, B.Vishnuram**,Hemavathy R**,Hariprasath*,Samathana Prabu I^

4 Rajkumar S*

6 Background
7 Vestibular elicited myogenic potential (VEMP) is utilized in the diagnosing various
8 vestibular diseases. VEMP uses many stimulants to stimulate the sensory
9 system and measure myogenic potentials.
10 Purpose
11 of this study was to match the results of tone burst and click on stimulation and Gender
12 difference in mVEMP on the latency and amplitude of myogenic potentials.
13 Research Design
14 Cross-Sectional Design Experimental Research was used.
15 Methods and analysis
16 Study includes 40 volunteers with a total of 80 ears. The masseter muscle potential of every ear
17 following a 500-Hz tone burst and click stimulation is measured in a sitting position and the
18 latency and amplitude is evaluated.
19 Results
20 The tone burst stimulation resulted in waves with longer latency (12.13 ± 0.81
21 ms) however higher amplitude (48.53 ± 25.64 µV) compared with the different stimuli, and also
22 the click stimulation resulted in waves with shorter latency (11.45 ± 0.87 ms) however lower
23 amplitude (31.23±18.56 µV) (p<0.001). The mVEMP asymmetry ratio failed
24 to significantly differ. Female have shorter latencies (12.06 ± 0.79 ms) and also shorter
25 amplitude (46.83 ± 18.69 µV) (p<0.005) than males. Asymmetric ratio was not significantly
26 different between each group.
27 Conclusion
28 Amplitudes and latencies of various stimuli and gender were significantly differ, studies need
29 more number of patients and stimulus varieties are to get standardized mVEMP results.
30

31 Keywords Vestibular System, Vestibular Evoked Myogenic Potential (VEMP),Vestiblo

32 trigeminal pathway, Masseter Vestibular evoked myogenic Responses(mVEMP),
33 Vestibulo-masseteric reflex.

34
35

36 INTRODUCTION:
37

38 The vestibular-evoked myogenic potential (VEMP) may be an objective

39 sound elicited technique supported by sensitivity of the acoustic residual responses in

40 sacculues, throughout the course of its development, functioned as associate degree organ of

41 hearing and still will therefore in primitive vertebrates. Sound-evoked vestibular responses in

42 humans was first described by Von Békésy, with intense sounds of 128 to

43 134 decibel, elicited head movement toward the ear which is stimulated. Movements in stapes

44 footplate, that lies in with reference to the sac, was thought to generate eddy current

45 formation inside the endolymph, hair cell displacement, and activation of primary afferents. High

46 intensity stimuli are accustomed elicit vestibular induced myogenic potential in

47 dynamic sternocleidomastoid muscles (cervical VEMP, cVEMP) and inferior oblique muscles

48 (ocular VEMP, oVEMP). For cVEMPs and oVEMPs, normative commonplace data’s area unit s

49 available. These tests have an enormous application in the investigation of each balance and

50 neurological issue. Vestibular incitement toward the end-organ level can likewise bring out a

51 short-inactivity subduing EMG reaction in dynamic facial muscles. This reaction was first

52 incontestable after one-sided or respective transmastoid electrical incitement as a two-sided and

53 even p11/n15 biphasic wave, named initially vestibulo-masseteric reflex (VMR). A lot

54 of recently research on masseteric VEMP (mVEMP) especially anatomical examinations led in

55 rats found that, other than a multisynaptic vestibulo-trigeminal pathway (Giaconi et al., 2006),

56 probably intervening stimulative long-latency cranial nerve reactions to proprioception

57 incitement (Tolu et al., 1996; Deriu et al., 1999; Deriu et al., 2000; Deriu et al., 2010), a single

58 reflex relationship between the medial proprioception cores and furthermore the cranial nerve
59 motor core exists (Cuccurazzu et al., 2007). In spite of the fact that not by the by affirmed in

60 people, this crossed and reciprocal vestibulo-trigeminal pathway can be the anatomical substrate

61 of the VMR (Deriu et al., 2010 ).More as of late, the mVEMP, was used as a piece of a far

62 reaching battery of VEMPs for the viable appraisal of the neural structure in patients with

63 Parkinson's unwellness (De Natale et al., 2015a, 2015b), REM-Sleep Behavior Disorder (de

64 Natale et al., 2018) and amyotrophic lateral sclerosis (Liu et al., 2019). A mVEMP score was

65 given to survey the seriousness of neural structure pathology in ailments (de Natale et al., 2015a,

66 2015b, 2018). These examinations suggest the utility of the mVEMP as apparatuses inside the

67 evaluation of neural structure work. Be that as it, dislike cVEMPs and oVEMPs, standardizing

68 information for mVEMP is missing, and this confines their latent capacity use in clinical settings.

69 Thusly this investigation intended to:

70 1) to search out the normative (peak latency, amplitude and asymmetric) for mVEMP with Tone

71 burst and Clicks

72 2) to search out the gender distinction in mVEMP

73

74 Methodology:

75 Subject: Study contain 40 volunteers (20 females and 20 males; mean

76 age 22 ± 2 years, vary 18-24 years) participated during this study, individual history was

77 gathered for all members to bar past or current ailments like neuro-otological and vestibular

78 disarranges, cervical spine aggravations and headache particularly, to preclude conductive and

79 sensori neural hearing issue. All members experienced tonal estimation (Maico MA 52)

80 assessment performed following global norms ISO 6189-1983. All members had customary
81 audiograms. Subjects were situated in a diminish and calm territory and were approached to

82 contract masseters at 30–50% of their top intentional compression, with visual input to help them

83 to watch their solid constriction level.

84 Recording parameters:

85 Stimulus:

86 During facial muscle contraction at the prescribed level, mVEMP were evoked through Tone

87 burst of 500Hz (n = 300–500 stimuli, 2-1-2 rise, plateau and fall, 5.1 Hz frequency),Vs. Tonal

88 Click stimulus (n = 300–500 stimuli,0.1 ms period, 5.1 Hz recurrence) created by a 3505 HP

89 electrical gadget driven by a symptom 5.0 content for VEMP (Cambridge Electronic style, LTD,

90 Cambridge, UK) and conveyed through TDH-39 name headphones (Telephonics, Huntington,

91 NY) monoaurally.. mVEMP is elcited at intensity of 90dBnHL. (Deriu et al., 2005, 2007).

92 Filter settings:

93 Unrectified and Rectified electromyogram action were respectively recorded (1902 Quad System

94 speaker, Cambridge Electronic LTD, Cambridge,UK), enhanced (x5000) with 5-5000Hz filter

95 and 10 KHz sampling frequency inside a 100 ms window (25 ms pre stimuli and 75 ms post

96 stimuli), victimization A simple/computerized device (1401 force, Cambridge Electronic style

97 LTD, Cambridge, UK) and Signal 5.0 code for PC.

98 Electrode Montage:

99 In all volunteers, electromyogram was recorded in facial muscle through bipolar silver/silver

100 chloride surface electrodes placed during a twofold belly-tendon configuration, the

101 active conductor placed within the facial muscles lower third position, passive conductor is

102 placed at the center of the arcus zygomaticus severally, and the common conductor at the

103 forehead. for every subject, the mVEMP were thought-about present once a p11/n21
104 wave, respectively, was plainly recognizable from the averaged background electrical activity,

105 estimated within the unrectified peaks, after they were >2SD of the pre-stimulus uncorrected

106 mean electromyogram.

107 The asymmetries in each p1 latencies and rectified amplitudes were determined with the

108 subsequent formula [(Lx - Rx/Lx + Rx) * 100%] wherever Lx and Rx represent the latency and

109 therefore the amplitudes of the left and right responses (Welgampola and Colebatch, 2001).

110 Inter-side variations in peak latencies were conjointly estimated.

111 Statistical analysis:

112 Data’s were computed and analysed through SPSS software. Statistical analysis was

113 performed as group comparison by means of the ANOVA in dependence of the data distribution

114 and homogenicity of variances. The tested significance level was P<0.05 (SPSS 10.0).

115 The impact of gender on the reflex morphology was tested with a one-way ANOVA with

116 Tukey’s posthoc test and Greenhouse-Geisser correction in case of nonspherical data, as

117 evaluated by Mauchly’s test.

118 Results:

119 The table 1 describes the results of the comparison of latencies of p11 and n21, peak-to-peak

120 p11-n21 amplitude and inter peak interval of Tone Burst and clicks evoked VEMP in healthy

121 individuals in which 20(50%)female and 20(50%) male participant with the mean age group of

122 22 ± 2 years.

123 The mean latencies of p11 for Click and Tone burst are as follows 11.45 ± 0.87 msec and 12.13

124 ± 0.81 msec ;Click and tone burst latency of n21 are 21.85 ± 1.65 and 22.54 ± 1.30 msec ; 10.4 ±
125 0.78 msec and 10.41 ± 0.49 msec were interpeak latency of p11-n21 and 31.23 ± 18.56 mV

126 amplitude for the click stimulus whereas amplitude for toneburst evoked is 48.53-25.64 mV .

127 The latencies p11, n21 and p11-n21 amplitude of Tone burst were significantly different from

128 those of m-VEMP (p <0.05, paired t test). The Asymmetric ratio of Tone burst and click evoked

129 responses were not significantly difference.

130 Table 1. comparison of Click and Tone burst evoked Vestibular evoked potential

131 * p <0.05, ** p <0.005 (two-tailed paired t-test).

132 ＋p <0.05 (Wilcoxon signed-rank test).

133 Data are expressed as mean ±SD.

134 The outcomes are summed up in Table 1. There were 20 (50%) female and 20 (50%) male

135 volunteers; their mean age was 22±2 (range, 18–24) years. We couldn't get a VEMP response in

136 either ear for two (2.5%) volunteers. Response rate with the tone burst stimulus was higher,

137 which is as per current writing. Longest wave latency is seen with the tone burst stimulus and

138 shortest with the click stimulus. The wave amplitude distribution results were similar. The P11

139 latency was statistically different among the both groups (p<0.001). A statistical difference was

140 found in the P11 amplitude value between the click and the tone-burst stimulus (p<0.001). The

141 Asymmetric ratio values did not statistically significantly differ.

142 In female, peak latencies of p1 and n1 were less significant in examination with male subjects.

143 Although measurable significance was found between the gender difference was very little as far

144 as outright values (normal distinction: 0.4 ms for the p11 and 1.0 ms for the n21).

145 On comparing different VEMP parameters between men and women, we found that there was no

146 significant difference as regards to threshold in the right ear (P=0.412) and threshold in the left

147 ear (P=0.630).p11 latency was also found to be non-significant (P=0.412 and P=0.987 for the
148 right and left ears, respectively). Moreover, n21 showed no significant difference (P=0.844 and

149 P=0.755 for the right and left ears, respectively).

150 Fig 1.The below graph describes the difference of latencies p11 and n21 among male vs female
151 and also with right and left
152

153 Table 2. describes the male and female difference data by latencies of p11, n21 interpeak interval
154 and amplitude
155 * p <0.05, ** p <0.005 (two-tailed paired t-test).

156 Discussion:

157 Masseter VEMP was obtained from all the 40 healthy subjects who participated in this study

158 based on the above-mentioned protocol. The latencies of p11,n21 and p11-n21 amplitude shows

159 significance difference whereas Asymmetric ratio does not have clinically significant difference.

160 More population should be needed to have a perfect reason for this non-significant value.

161 The latency of p11 and n21 of Tone burst were seems be longer than the latencies evoked by

162 click stimulus. This prolongation in the peak latencies maybe the change in 1 milisecond rise/fall

163 time of the tone burst stimulus (Ostrowski et al., 2001). The neurons in the vestibular system

164 may have double/triple firing rate to the rise/fall time in the tone burst stimulus which results in

165 the delayed second or third spikes in neuronal firing (Cheng et al., 2001a,2003)

166 Significant difference in inter peak latency of p11-n21 may be due to the shorter(0.3ms) rise/fall

167 time of click stimulus than longer (1 ms) rise/fall time of tone burst stimulus which results in

168 evoked responses without inducing the stapedial reflex(Cheng et at., 2001a) however, the

169 stapedial reflex tenses the tympanic membrane to avoid its damage caused by the high intensity

170 stimulus(Cheng et al.,2001a;2001b; Salomon G 1996; Wu and young et al., 2002).Asymmetric

171 ratio was not significantly difference between Tone burst and click in this study same as in other
172 studies by Su et al., 2004; Cheng et al.,2001a,2001b,2003;Salomon.,1996; Wu and young et al.,

173 2002.

174 In reference with the previous lines which compare the male and female evoked cVEMP(Ochi

175 and Ohashi, 2003) and oVEMP(Sung et al., 2011; Versino et al., 2015) which were published in

176 past few years shows their results in contrast with our studies which shows the negative

177 significance difference between male and female. Whereas in this study significant difference

178 was found in the peak latency, the shorter peak latency in female than males. This is may be

179 because of the effect which is seen in Auditory Brainstem Responses described by (Beagley and

180 Sheldrake, 1978; Trune et al., 1988).There is also some studies which hypothesized the

181 difference may be because of the lower cochlear average length(Sato et al.,1991) however Miller,

182 (2007) disagree with the above statement on supporting to the above hypotheses caloric response

183 shows no difference exist in peripheral vestibular pathway between male and females. Studies to

184 done with more sample size to clarify the presence and the cause for the disagreements.

185

186 Conclusion:

187 Tone burst have larger peak amplitude compared to clicks although peak latencies are prolonged

188 in tone burst is useful to find the peaks easier compared to clicks induced mVEMP. There's no

189 statistically significance difference between male and female.

190 The previous studies done by Colebatch et al in 1994, Cheng et al in 2003, Su et al in

191 2004. Taipeh et al 2007 show the difference in vestibular evoked potential using clicks and tone

192 burst. In mVEMP there's lack of normative information on comparison of tone burst and click.

193 Still a lot of controversies were found in ipsi and conta presentation in this study . In conclusion,

194 the VEMP responses were considerably different between the stimuli of TB and click. The Tone
195 Burst-VEMP had longer latencies p11 and n21 than mVEMP. The norms of

196 various stimuli should be established for clinical interpretations. For

197 clinical diagnosing using VEMP, we tend to suggest Tone Burst stimuli as a result of the

198 latencies and amplitudes of click were significantly different among many labs, as well as ours.

199 Clinical implications.

200 VEMPs are progressively utilized for examine and clinical purposes in a wide number of

201 neurological and neurotological issue, with an indicative/differential diagnostic reason. The

202 reflexes here tried can in a roundabout way study a huge segment of the brainstem and have been

203 demonstrated a helpful complement to cervical and ocular VEMPs in the investigation of

204 brainstem functions (Magnano et al., 2014; de Natale et al., 2015a, 2015b, 2018; Magnano et al.,

205 2016; de Natale et al. 2016). mVEMP has the upside of researching the trigeminal brainstem

206 pathways and is more endured than the Trigeminal Cervical Reflex (which infers an incitement

207 which, in spite of the fact that not nociceptive, can be upsetting for the subject). mVEMP

208 additionally gives a crossed and reciprocal reaction to mono or two-sided incitements; this

209 element might be helpful while separating central neurological and peripheral vestibular

210 disarranges. In the last case, debilitations in the incitement of the influenced side (peripheral

211 vestibular dysfunction) can be offset the conservation of the VMR reaction on the relating

212 objective muscle from stimulation from contralateral side (Central pathway preservation).

213 Limitations:

214 1) Sample is small for generalization

215 2) Various frequency of Tone burst stimulus can be used

216
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391 central neurological disorders. Clin Neurophysiol2016;127:40–9.
392

393 Versino M, Colnaghi S, Ranzani M, Alloni R, Bolis C, Sacco S, et al. Ocular vestibular evoked
394 myogenic potentials in response to air-conducted 500 Hz short tones:
395 Effect of stimulation procedure (monaural or binaural), age and gender. J Vestib Res
396 2015;25:143–9.
397

398 Welgampola MS, Colebatch JG. Vestibulocollic reflexes: normal values and the effect of age.
399 Clin Neurophysiol2001;112:1971–9.
400

401 Wu CC, Young YH. Vestibular evoked myogenic potentials are intact after sudden deafness. Ear
402 Hear 2002;23:235–8.
Manuscript - anonymous Click here to access/download;Manuscript - anonymous;mVEMP
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1 Masseteric Vestibular Evoked Myogenic Potential Click Vs.

2 Toneburst Normative and gender difference

3 Background
4 Vestibular elicited myogenic potential (VEMP) is utilized in the diagnosing various
5 vestibular diseases. VEMP uses many stimulants to stimulate the sensory
6 system and measure myogenic potentials.
7 Purpose
8 of this study was to match the results of tone burst and click on stimulation and Gender
9 in mVEMP on the latency and amplitude of myogenic potentials.
10 Research Design
11 Cross-Sectional Design Experimental Research was used.
12 Methods and analysis
13 Study includes 40 volunteers with a total of 80 ears. The masseter muscle potential of every ear
14 following a 500-Hz tone burst and click stimulation is measured in a sitting position and the
15 latency and amplitude is evaluated.
16 Results
17 The tone burst stimulation resulted in waves with longer latency (12.13 ± 0.81
18 ms) however higher amplitude (48.53 ± 25.64 µV) compared with the different stimuli, and also
19 the click stimulation resulted in waves with shorter latency (11.45 ± 0.87 ms) however lower
20 amplitude (31.23±18.56 µV) (p<0.001). The mVEMP asymmetry ratio failed
21 to significantly differ. Female have shorter latencies (12.06 ± 0.79 ms) and also shorter
22 (46.83 ± 18.69 µV) (p<0.005) than males. Asymmetric ratio was not significantly different
23 between each group.
24 Conclusion
25 Amplitudes and latencies of various stimuli and gender were significantly differ, studies need
26 more number of patients and stimulus varieties are to get standardized mVEMP results.
27

28 Keywords Vestibular System, Vestibular Evoked Myogenic Potential (VEMP),Vestiblo

29 trigeminal pathway, Masseter Vestibular evoked myogenic Responses(mVEMP),
30 Vestibulo-masseteric reflex.

31
32

33 INTRODUCTION:
34
35 The vestibular-evoked myogenic potential (VEMP) may be an objective

36 sound elicited technique supported by sensitivity of the acoustic residual responses in

37 sacculues, throughout the course of its development, functioned as associate degree organ of

38 hearing and still will therefore in primitive vertebrates. Sound-evoked vestibular responses in

39 humans was first described by Von Békésy, with intense sounds of 128 to

40 134 decibel, elicited head movement toward the ear which is stimulated. Movements in stapes

41 footplate, that lies in with reference to the sac, was thought to generate eddy current

42 formation inside the endolymph, hair cell displacement, and activation of primary afferents. High

43 intensity stimuli are accustomed elicit vestibular induced myogenic potential in

44 dynamic sternocleidomastoid muscles (cervical VEMP, cVEMP) and inferior oblique muscles

45 (ocular VEMP, oVEMP). For cVEMPs and oVEMPs, normative commonplace data’s area unit s

46 available. These tests have an enormous application in the investigation of each balance and

47 neurological issue. Vestibular incitement toward the end-organ level can likewise bring out a

48 short-inactivity subduing EMG reaction in dynamic facial muscles. This reaction was first

49 incontestable after one-sided or respective transmastoid electrical incitement as a two-sided and

50 even p11/n15 biphasic wave, named initially vestibulo-masseteric reflex (VMR). A lot

51 of recently research on masseteric VEMP (mVEMP) especially anatomical examinations led in

52 rats found that, other than a multisynaptic vestibulo-trigeminal pathway (Giaconi et al., 2006),

53 probably intervening stimulative long-latency cranial nerve reactions to proprioception

54 incitement (Tolu et al., 1996; Deriu et al., 1999; Deriu et al., 2000; Deriu et al., 2010), a single

55 reflex relationship between the medial proprioception cores and furthermore the cranial nerve

56 motor core exists (Cuccurazzu et al., 2007). In spite of the fact that not by the by affirmed in

57 people, this crossed and reciprocal vestibulo-trigeminal pathway can be the anatomical substrate
58 of the VMR (Deriu et al., 2010 ).More as of late, the mVEMP, was used as a piece of a far

59 reaching battery of VEMPs for the viable appraisal of the neural structure in patients with

60 Parkinson's unwellness (De Natale et al., 2015a, 2015b), REM-Sleep Behavior Disorder (de

61 Natale et al., 2018) and amyotrophic lateral sclerosis (Liu et al., 2019). A mVEMP score was

62 given to survey the seriousness of neural structure pathology in ailments (de Natale et al., 2015a,

63 2015b, 2018). These examinations suggest the utility of the mVEMP as apparatuses inside the

64 evaluation of neural structure work. Be that as it, dislike cVEMPs and oVEMPs, standardizing

65 information for mVEMP is missing, and this confines their latent capacity use in clinical settings.

66 Thusly this investigation intended to:

67 1) to search out the normative (peak latency, amplitude and asymmetric) for mVEMP with Tone

68 burst and Clicks

69 2) to search out the gender distinction in mVEMP

70

71 Methodology:

72 Subject: Study contain 40 volunteers (20 females and 20 males; mean

73 age 22 ± 2 years, vary 18-24 years) participated during this study, individual history was

74 gathered for all members to bar past or current ailments like neuro-otological and vestibular

75 disarranges, cervical spine aggravations and headache particularly, to preclude conductive and

76 sensori neural hearing issue. All members experienced tonal estimation (Maico MA 52)

77 assessment performed following global norms ISO 6189-1983. All members had customary

78 audiograms. Subjects were situated in a diminish and calm territory and were approached to

79 contract masseters at 30–50% of their top intentional compression, with visual input to help them
80 to watch their solid constriction level.

81 Recording parameters:

82 Stimulus:

83 During facial muscle contraction at the prescribed level, mVEMP were evoked through Tone

84 burst of 500Hz (n = 300–500 stimuli, 2-1-2 rise, plateau and fall, 5.1 Hz frequency),Vs. Tonal

85 Click stimulus (n = 300–500 stimuli,0.1 ms period, 5.1 Hz recurrence) created by a 3505 HP

86 electrical gadget driven by a symptom 5.0 content for VEMP (Cambridge Electronic style, LTD,

87 Cambridge, UK) and conveyed through TDH-39 name headphones (Telephonics, Huntington,

88 NY) monoaurally.. mVEMP is elcited at intensity of 90dBnHL. (Deriu et al., 2005, 2007).

89 Filter settings:

90 Unrectified and Rectified electromyogram action were respectively recorded (1902 Quad System

91 speaker, Cambridge Electronic LTD, Cambridge,UK), enhanced (x5000) with 5-5000Hz filter

92 and 10 KHz sampling frequency inside a 100 ms window (25 ms pre stimuli and 75 ms post

93 stimuli), victimization A simple/computerized device (1401 force, Cambridge Electronic style

94 LTD, Cambridge, UK) and Signal 5.0 code for PC.

95 Electrode Montage:

96 In all volunteers, electromyogram was recorded in facial muscle through bipolar silver/silver

97 chloride surface electrodes placed during a twofold belly-tendon configuration, the

98 active conductor placed within the facial muscles lower third position, passive conductor is

99 placed at the center of the arcus zygomaticus severally, and the common conductor at the

100 forehead. for every subject, the mVEMP were thought-about present once a p11/n21

101 wave, respectively, was plainly recognizable from the averaged background electrical activity,
102 estimated within the unrectified peaks, after they were >2SD of the pre-stimulus uncorrected

103 mean electromyogram.

104 The asymmetries in each p1 latencies and rectified amplitudes were determined with the

105 subsequent formula [(Lx - Rx/Lx + Rx) * 100%] wherever Lx and Rx represent the latency and

106 therefore the amplitudes of the left and right responses (Welgampola and Colebatch, 2001).

107 Inter-side variations in peak latencies were conjointly estimated.

108 Statistical analysis:

109 Data’s were computed and analysed through SPSS software. Statistical analysis was

110 performed as group comparison by means of the ANOVA in dependence of the data distribution

111 and homogenicity of variances. The tested significance level was P<0.05 (SPSS 10.0).

112 The impact of gender on the reflex morphology was tested with a one-way ANOVA with

113 Tukey’s posthoc test and Greenhouse-Geisser correction in case of nonspherical data, as

114 evaluated by Mauchly’s test.

115 Results:

116 The table 1 describes the results of the comparison of latencies of p11 and n21, peak-to-peak

117 p11-n21 amplitude and inter peak interval of Tone Burst and clicks evoked VEMP in healthy

118 individuals in which 20(50%)female and 20(50%) male participant with the mean age group of

119 22 ± 2 years.

120 The mean latencies of p11 for Click and Tone burst are as follows 11.45 ± 0.87 msec and 12.13

121 ± 0.81 msec ;Click and tone burst latency of n21 are 21.85 ± 1.65 and 22.54 ± 1.30 msec ; 10.4 ±

122 0.78 msec and 10.41 ± 0.49 msec were interpeak latency of p11-n21 and 31.23 ± 18.56 mV

123 amplitude for the click stimulus whereas amplitude for toneburst evoked is 48.53-25.64 mV .
124 The latencies p11, n21 and p11-n21 amplitude of Tone burst were significantly different from

125 those of m-VEMP (p <0.05, paired t test). The Asymmetric ratio of Tone burst and click evoked

126 responses were not significantly difference.

127 Table 1. comparison of Click and Tone burst evoked Vestibular evoked potential

128 * p <0.05, ** p <0.005 (two-tailed paired t-test).

129 ＋p <0.05 (Wilcoxon signed-rank test).

130 Data are expressed as mean ±SD.

131 The outcomes are summed up in Table 1. There were 20 (50%) female and 20 (50%) male

132 volunteers; their mean age was 22±2 (range, 18–24) years. We couldn't get a VEMP response in

133 either ear for two (2.5%) volunteers. Response rate with the tone burst stimulus was higher,

134 which is as per current writing. Longest wave latency is seen with the tone burst stimulus and

135 shortest with the click stimulus. The wave amplitude distribution results were similar. The P11

136 latency was statistically different among the both groups (p<0.001). A statistical difference was

137 found in the P11 amplitude value between the click and the tone-burst stimulus (p<0.001). The

138 Asymmetric ratio values did not statistically significantly differ.

139 In female, peak latencies of p1 and n1 were less significant in examination with male subjects.

140 Although measurable significance was found between the gender difference was very little as far

141 as outright values (normal distinction: 0.4 ms for the p11 and 1.0 ms for the n21).

142 On comparing different VEMP parameters between men and women, we found that there was no

143 significant difference as regards to threshold in the right ear (P=0.412) and threshold in the left

144 ear (P=0.630).p11 latency was also found to be non-significant (P=0.412 and P=0.987 for the

145 right and left ears, respectively). Moreover, n21 showed no significant difference (P=0.844 and

146 P=0.755 for the right and left ears, respectively).

147 Fig 1.The below graph describes the difference of latencies p11 and n21 among male vs female
148 and also with right and left
149

150 Table 2. describes the male and female difference data by latencies of p11, n21 interpeak interval
151 and amplitude
152 * p <0.05, ** p <0.005 (two-tailed paired t-test).

153 Discussion:

154 Masseter VEMP was obtained from all the 40 healthy subjects who participated in this study

155 based on the above-mentioned protocol. The latencies of p11,n21 and p11-n21 amplitude shows

156 significance difference whereas Asymmetric ratio does not have clinically significant difference.

157 More population should be needed to have a perfect reason for this non-significant value.

158 The latency of p11 and n21 of Tone burst were seems be longer than the latencies evoked by

159 click stimulus. This prolongation in the peak latencies maybe the change in 1 milisecond rise/fall

160 time of the tone burst stimulus (Ostrowski et al., 2001). The neurons in the vestibular system

161 may have double/triple firing rate to the rise/fall time in the tone burst stimulus which results in

162 the delayed second or third spikes in neuronal firing (Cheng et al., 2001a,2003)

163 Significant difference in inter peak latency of p11-n21 may be due to the shorter(0.3ms) rise/fall

164 time of click stimulus than longer (1 ms) rise/fall time of tone burst stimulus which results in

165 evoked responses without inducing the stapedial reflex(Cheng et at., 2001a) however, the

166 stapedial reflex tenses the tympanic membrane to avoid its damage caused by the high intensity

167 stimulus(Cheng et al.,2001a;2001b; Salomon G 1996; Wu and young et al., 2002).Asymmetric

168 ratio was not significantly difference between Tone burst and click in this study same as in other

169 studies by Su et al., 2004; Cheng et al.,2001a,2001b,2003;Salomon.,1996; Wu and young et al.,

170 2002.
171 In reference with the previous lines which compare the male and female evoked cVEMP(Ochi

172 and Ohashi, 2003) and oVEMP(Sung et al., 2011; Versino et al., 2015) which were published in

173 past few years shows their results in contrast with our studies which shows the negative

174 significance difference between male and female. Whereas in this study significant difference

175 was found in the peak latency, the shorter peak latency in female than males. This is may be

176 because of the effect which is seen in Auditory Brainstem Responses described by (Beagley and

177 Sheldrake, 1978; Trune et al., 1988).There is also some studies which hypothesized the

178 difference may be because of the lower cochlear average length(Sato et al.,1991) however Miller,

179 (2007) disagree with the above statement on supporting to the above hypotheses caloric response

180 shows no difference exist in peripheral vestibular pathway between male and females. Studies to

181 done with more sample size to clarify the presence and the cause for the disagreements.

182

183 Conclusion:

184 Tone burst have larger peak amplitude compared to clicks although peak latencies are prolonged

185 in tone burst is useful to find the peaks easier compared to clicks induced mVEMP. There's no

186 statistically significance difference between male and female.

187 The previous studies done by Colebatch et al in 1994, Cheng et al in 2003, Su et al in

188 2004. Taipeh et al 2007 show the difference in vestibular evoked potential using clicks and tone

189 burst. In mVEMP there's lack of normative information on comparison of tone burst and click.

190 Still a lot of controversies were found in ipsi and conta presentation in this study . In conclusion,

191 the VEMP responses were considerably different between the stimuli of TB and click. The Tone

192 Burst-VEMP had longer latencies p11 and n21 than mVEMP. The norms of

193 various stimuli should be established for clinical interpretations. For

194 clinical diagnosing using VEMP, we tend to suggest Tone Burst stimuli as a result of the

195 latencies and amplitudes of click were significantly different among many labs, as well as ours.

196 Clinical implications.

197 VEMPs are progressively utilized for examine and clinical purposes in a wide number of

198 neurological and neurotological issue, with an indicative/differential diagnostic reason. The

199 reflexes here tried can in a roundabout way study a huge segment of the brainstem and have been

200 demonstrated a helpful complement to cervical and ocular VEMPs in the investigation of

201 brainstem functions (Magnano et al., 2014; de Natale et al., 2015a, 2015b, 2018; Magnano et al.,

202 2016; de Natale et al. 2016). mVEMP has the upside of researching the trigeminal brainstem

203 pathways and is more endured than the Trigeminal Cervical Reflex (which infers an incitement

204 which, in spite of the fact that not nociceptive, can be upsetting for the subject). mVEMP

205 additionally gives a crossed and reciprocal reaction to mono or two-sided incitements; this

206 element might be helpful while separating central neurological and peripheral vestibular

207 disarranges. In the last case, debilitations in the incitement of the influenced side (peripheral

208 vestibular dysfunction) can be offset the conservation of the VMR reaction on the relating

209 objective muscle from stimulation from contralateral side (Central pathway preservation).

210 Limitations:

211 1) Sample is small for generalization

212 2) Various frequency of Tone burst stimulus can be used

213

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388 central neurological disorders. Clin Neurophysiol2016;127:40–9.
389

390 Versino M, Colnaghi S, Ranzani M, Alloni R, Bolis C, Sacco S, et al. Ocular vestibular evoked
391 myogenic potentials in response to air-conducted 500 Hz short tones:
392 Effect of stimulation procedure (monaural or binaural), age and gender. J Vestib Res
393 2015;25:143–9.
394

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396 Clin Neurophysiol2001;112:1971–9.
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398 Wu CC, Young YH. Vestibular evoked myogenic potentials are intact after sudden deafness. Ear
399 Hear 2002;23:235–8.
Table

TABLE 1
VEMP Latency p11 Latency n21 Interval (p11- Amplitude(p11-n21) Asymmetric
n21) (msec) ratio
(msec) (msec) (μV)

Clicks 11.45 ± 0.87** 21.85 ± 1.65** 10.4 ± 0.78* 31.23 ± 18.56*＋ 15.82 ± 12.16

Tone 12.13 ± 0.81** 22.54 ± 1.30** 10.41± 0.49* 48.53 ± 25.64*＋ 16.18 ± 13.23
burst

TABLE 2
Latency p11 Latency n21 Interval (p11- Amplitude
(msec) n21) (msec) (p11-n21) (μV)
(msec)

Male 12.13 ± 0.93* 23.12 ± 1.03** 10.51 ± 0.48* 48.54 ± 21.38

Female 12.06 ± 0.79* 21.02 ± 0.99 ** 10.01 ± 0.11 46.83 ± 18.69

Fig 1

Male Female Vs Right Left

Male Female

25 23.66 23.53 23.61 23.51

20

15 12.53 11.65 12.16 11.87

10

0
Lt P11 Lt N21 Rt P11 Rt N21
Cover

Masseteric Vestibular Evoked Myogenic Potential Click Vs.

Toneburst Normative and gender difference

Aparna Ravichandran***,B.Vishnuram**, Samathana Prabu I**,Hemavathy R**,Hariprasath*,

Author information:

*** Lecturer in Speech & Hearing, Department of Audiology, Ali Yavar Jung National Institute

for Speech and Hearing Disability, Regional Centre, Secundrabad.

**Final year MSc Audiology, AYJNISHD, RC, Secundrabad

Ali Yavar Jung National Institute for Speech and Hearing Disability, Regional Centre,

Secundrabad.

*First year MASLP,

Sweekaar Academy of Rehabilitation Sciences,

Secunderabad.

Address for Correspondence

Mr.B. Vishnuram

M. Sc (Audiology)

Ali Yavar Jung National Institite Of Speech and Hearing Disabilities, Regional Centre,

Secundrabad

vishuvishnu26@gmail.com