Journal of Otolaryngology Head & Neck Surgery Category: Clinical Type: Research Article
The Sensitivity and Specificity of Vestibular Evoked Myogenic Potential (VEMP) in the Diagnosis of Definite Ménière’s Disease Patients
- Chanchai Jariengprasert1*, Suwimol Ruencharoen2, Montip Tiensuwan3
- 1 Department Of Otolaryngology, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
- 2 Department Of Communication Sciences And Disorders, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
- 3 Department Of Mathematics, Mahidol University, Bangkok, Thailand
*Corresponding Author:Chanchai Jariengprasert
Department Of Otolaryngology, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
Received Date: Mar 14, 2017 Accepted Date: Jun 07, 2017 Published Date: Jun 21, 2017
This study was a retrospective review of the data to compare the sensitivity and specificity of cervical VEMP (cVEMP) in unilateral definite Ménière’s Disease (MD) patients with those in Vestibular Migraine (VM) and control subjects.
Material and Method
All patients diagnosed as unilateral definite MD and Vestibular Migraine (VM) patients and normal control adults whom underwent cVEMP tests with short tone burst of 500 Hz. at 95 dBHL during January 2007 - December 2015 were included in this study. Age, gender, routine audiometric and cVEMP results were collected. SPSS for windows was used in data analysis; F - test, Chi - square and Fisher’s exact test were used for comparison of the means and percentages.
The unilateral definite MD group (22 males, 45 females) had mean age of 50.62 ± 9.41 years and mean Pure Tone Average (PTA) in the affected ears (Rt.ear = 37, Lt. ear = 30) of 45.95 ± 22.58 dBHL. The VM group (5 males, 51 females) had mean age of 49.04 ± 9.85 years and mean PTA in Rt. and Lt. ears of 18.96 ± 7.65 and 19.41 ± 7.96 dBHL, respectively. Normal control adults (13 males, 19 females) had mean age of 45.47 ± 9.54 years and mean PTA on both ears of 16.02 ± 6.28 dBHL. The percentage of abnormal cVEMP result found in the MD group was significantly different from those in the VM (62.68% vs 19.64%; Fisher’s exact test, p<0.0001) and control groups (62.68% vs 3.12%; Fisher’s exact test, p<0.0001). The sensitivity and specificity of cVEMP in MD were 62.68 and 96.88%, respectively. The percentage of abnormal cVEMP in MD was significantly higher than those in the VM and control groups.
The percentage of abnormal cVEMP in MD was highly significant over those in VM and control groups. Although the sensitivity of cVEMP in unilateral MD was not dominantly better than other vestibular test battery for the diagnosis of MD, these findings supported more saccular dysfunction, the second most often occurred lesion, in MD than in VM group. However, the high specificity (96.88%) of abnormal cVEMP in MD and VM showed non-specific pathology involving the saccule. The results suggested that cVEMP should be used as a confirmative test or for staging of the disease progression to differentiate between MD vs. VM rather than a screening test for detection of hydrops.
Vestibular migraine and MD seem to share some similar clinical symptoms and laboratory profiles . Many studies investigated cVEMP sensitivity in Ménière’s patients showing various results ranged from 50% to 75% [17-28]. To set our laboratory protocols, this retrospective review in Thai patients aimed to compare the sensitivity and specificity of the cVEMP results in unilateral definite MD patients with those in vestibular migraine patients and healthy controls.
SUBJECTS AND METHODS
The cVEMP data from 32 healthy control subjects described in the previous report were used as normal controls . Each subject gave a detailed history and underwent physical examination, a routine audiometry, and the cVEMP tests using 500 Hz tone burst at 95 dBHL as stimulus . The measurement of cVEMP response, which was considered “abnormal,” included absent response or abnormal Asymmetry Ratio (AR). The 35% cut - off was used as the upper limit of normal AR response in Thai subjects .
|Data||MD||VM||Control||P - value|
|(n = 67)||(n = 56)||(n = 32)|
|Age (mean + SD) years||50.62 + 9.41||49.04 + 9.85||45.47 + 9.54||0.066|
|Sex - Female (%)||45 (67.17)||51 (91.07)*||19 (59.37)||<0.05|
|Male (%)||22 (32.83)||5 (8.93)||13 (40.63)|
|PTA (mean + SD) dBHL||Affected ears||RE = 18.96 + 7.65||Both ears||<0.001|
|45.95 + 22.58*||LE = 19.41 + 7.96||16.02 + 6.28|
*Significant difference from other groups.
Table 2 shows that 62.68% of the patients in the MD group, compared to nearly 20% of the patients in the VM group, had abnormal cVEMP responses. Only one subject in the control group showed abnormal cVEMP response. The Chi - square test of cVEMP and disease status percentages showed a significant difference at p
The sensitivity and specificity of the cVEMP in the MD group were 62.68%, and 96.88%, respectively, whereas those of the cVEMP in the VM group were 19.64% and 96.88%, respectively.
|n (%)||n (%)||n (%)|
|Abnormal||42 (62.68)||11 (19.64)||1 (3.12)||42.76||<0.001|
|Normal||25 (37.32)||45 (80.36)||31 (96.88)|
|Total||67 (100)||56 (100)||32 (100)|
The Chi - square test did not show a significant difference in the proportion of patients with normal and abnormal cVEMP results based on different stages (p = 0.26, Table 3) and the duration of onset in the MD group (p = 0.30, Table 4). The proportions of individuals with abnormal cVEMP responses, however, appeared to be higher in those at stages 3 & 4 of MD than those at stages 1 & 2. Similarly, the proportions of individuals with abnormal cVEMP responses tended to be higher among the patients with more than 10 years of the disease onset than those with less than 10 years.
|Stage||Abnormal||Normal||Total||X2||P - value|
|n (%)||n (%)||n (%)|
|I||16 (57.14)||12 (42.86)||28 (100)||2.69||0.26|
|II||16 (59.26)||11 (40.74)||27 (100)|
|III & IV||10 (83.33)||2 (16.67)||12 (100)|
|Total||42 (62.69)||25 (37.31)||67 (100)|
|Duration||Abnormal||Normal||Total||X2||P - Value|
|(years)||n (%)||n (%)||n (%)|
|≤ 5||21 (60.0)||14 (40.0)||35 (100)||2.408||0.3|
|>5 - ≤10||14 (58.33)||10 (41.67)||24 (100)|
|>10||7 (87.50)||1 (12.50)||8 (100)|
|Total||42 (62.69)||25 (37.31)||67 (100)|
The sensitivity of cVEMP in patients with MD has been reported with various results, ranging from 50% to 75% [17-28]. Various authors have investigated cVEMP in MD and have taken a wide range of parameters into consideration [17-24,28-30]. Rauch et al.,  studied VEMP recordings from 14 normal individuals compared to those from 34 patients with MD. They found a significant difference in cVEMP amplitudes among normal ears, unaffected MD ears and affected ears. With the low frequency tone bursts, the cVEMP was presented in all normal subjects but only in 82 - 85% of MD ears. Later, they also studied the clinical assignment of side - of - disease in 20 unilateral Ménière’s subjects to side assignment using AAO - HNS clinical criteria and previous audiogram as gold standard compared to cVEMP interaural threshold difference, caloric asymmetry, and multivariate statistical analysis of a vestibular test battery. Their results showed that the accurate method of side assignment scored correctly by 250 Hz. The sensitivity of cVEMP was 80% and that for the click cVEMP was 55% . Taylor et al., combined measurement of cVEMP by using an abnormally low 0.5/1 kHz frequency ratio and/or an elevated 0.5 kHz AR. They found a sensitivity of 75% and specificity of 80% in differentiating MD from VM .
Difference in the percentage of abnormal cVEMP results in MD might be due to differences in the protocol of study using TB of 500 Hz that showed less sensitivity of using 1000 Hz. (resonance frequency tuning shift)  and also due to the number of study subjects and variation in disease staging. Our study focused on the laboratory protocol, and the 500 Hz tone burst for cVEMP testing was used for other vestibular disorders as well. However, when the test is abnormal, all patients should have some pathology in the saccule, e.g., endolymphatic hydrops or ischemic process.
In MD, the ECochG is aimed mainly to identify cochlear hydrops; meanwhile, a caloric test is used for the detection of horizontal semicircular canal function. The sensitivity of ECochG was about 60-65% using ear tip-trode [3-6] and the sensitivity of acaloric test was about 48 - 74% using 25 - 30% interaural different criterion [7,8,10], while the test using dehydrating agents showed 50 - 60% of sensitivity [11,12]. Although the sensitivity of cVEMP in this present study was not superior to the previous audio-vestibular tests (ECochG, caloric test, dehydrating agent), cVEMP was easier to perform, less uncomfortable, and well tolerated by patients. In addition, the cVEMP test had no risk of hypotension, dizziness, nausea, vomiting, or muscle weakness, in contrast to the test using dehydrating agents or a caloric test. From clinical observations, the ECochG test took more time to operate than the cVEMP test in the same cases. Moreover, it could be performed on patients with severe to profound hearing loss in which the ECochG test was confounded because of its limitation. Hence, the cVEMP test should be included as one of the audio - vestibular test battery for MD or other vestibular disorders suspected for a saccular portion involvement.
A controversy was found in the cVEMP investigation in MD as the percentage of abnormal cVEMP should be greater in more advanced stages of the disease [31,33-35]. Moreover, a saccular involvement showed to have a greater chance of having poor hearing outcome . More importance in identifying abnormal cVEMP on unaffected ear (35%) should alert a physician for possible subclinical hydrops on the good ear . Our study found a higher percentage of abnormal cVEMP in later stages (stage 3+4 = 83.33%) than in earlier stages and also with longer durations of onset (>10 years = 87.5%) than shorter durations; however, this was not statistically significant. There might be variation in a small number of subjects especially in the more severe and longer duration group.
The limitation of this study is a single institutional study with relatively small sample size in each group particularly the control group. However, our findings suggest that the cVEMP shows a fair effect as a screening tool due to a slightly low sensitivity (62.68%) depending on disease staging, but it could be used for identifying saccular involvement in the case of definite MD because of its high specificity (96.88%). The results also suggest that cVEMP should be used as a confirmative test or for staging of the disease progression to differentiate between MD vs. VM patients rather than a screening test for the detection of hydrops. Further study should be investigated for more information regarding the exact parameter which could improve the cVEMP testing protocol.
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Citation:Jariengprasert C, Ruencharoen S, Reddy NV, Tiensuwan M (2017) The Sensitivity and Specificity of Vestibular Evoked Myogenic Potential (VEMP) in the Diagnosis of Definite Ménière’s Disease Patients. J Otolaryng Head Neck Surg 3: 009.
Copyright: © 2017 Chanchai Jariengprasert, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.