Introduction
Ménière’s disease is an inner-ear disorder due to endolymphatic hydrops and it is marked by recurrent vertigo episodes, fluctuating hearing loss, and tinnitus.Reference Kitano, Kitahara, Ito, Shiozaki, Wada and Yamanaka1, Reference Canale, Caranzano, Lanotte, Ducati, Calamo and Albera2 It is a prevalent disorder, occurring at a rate of 15–50 cases per 100,000 individuals.Reference Kitano, Kitahara, Ito, Shiozaki, Wada and Yamanaka1 In most cases, the disease follows a gradual progression and has a substantial effect on the affected individual’s Ménière’s disease. The current diagnostic criteria for Ménière’s disease, jointly formulated by the Classification Committee of the Bárány Society in 2015, were classified into two types: definite Ménière’s disease and probable Ménière’s disease.Reference Koenen and Andaloro3, Reference Lopez-Escamez, Carey, Chung, Goebel, Magnusson and Mandalà4 One of the major differences is the audiological findings. The consensus statement defined “Low-frequency SNHL [sensorineural hearing loss] is defined as increases in pure tone thresholds for bone-conducted sound that are higher (i.e. worse) in the affected ear than the contralateral ear by at least 30 dB HL at each of two contiguous frequencies below 2000 Hz. In cases of bilateral low-frequency SNHL, the absolute thresholds for bone-conducted sound must be 35 dB HL or higher at each of two contiguous frequencies below 2000 Hz” for hearing loss.Reference Lopez-Escamez, Carey, Chung, Goebel, Magnusson and Mandalà4
Although audiological findings are clearly defined to distinguish probable Ménière’s disease and definite Ménière’s disease, there are no objective test criteria for vestibular tests. Vestibular function tests have been used to explore the extent of impairment to the vestibular apparatus in Ménière’s disease.Reference Egami, Ushio, Yamasoba, Yamaguchi, Murofushi and Iwasaki5 Presently, the functional assessment of the vestibular end-organ allows accurate monitoring of activity within the posterior labyrinth. Caloric stimuli are employed to examine the functionality of the horizontal semicircular canal, while myogenic evoked potentials like cervical-vestibular evoked myogenic potentials and ocular-vestibular evoked myogenic potentials are utilised to respectively evaluate the function of the saccule and the utricle.Reference Canale, Caranzano, Lanotte, Ducati, Calamo and Albera2 In the literature, vestibular tests such as caloric, cervical-vestibular evoked myogenic potentials and ocular-vestibular evoked myogenic potentials are frequently used in Ménière’s disease diagnosis.Reference Huang, Wang and Young6, Reference Taha, Nada, Alagamy and Rahman7 Egami et al. suggested that these tests can aid the diagnostic process in Ménière’s disease.Reference Egami, Ushio, Yamasoba, Yamaguchi, Murofushi and Iwasaki5 However, Huang et al. found no significant correlation between caloric tests and ocular-vestibular evoked myogenic potentials results, and Taha et al. reported moderate sensitivity for cervical-vestibular evoked myogenic potentials in diagnosing Ménière’s disease.Reference Huang, Wang and Young6, Reference Taha, Nada, Alagamy and Rahman7
Considering the anatomical proximity, it can be expected that the vestibular system will be less functionally affected due to the limited hearing impairment in the case of probable Ménière’s disease. In this study, we divided Ménière’s disease patients into two groups (probable and definite), and compared their vestibular evoked myogenic potentials and caloric test results. Additionally, we analysed the vestibular evoked myogenic potentials test outcomes and auditory complaints based on the ear affected by Ménière’s disease. Although there are many studies on Ménière’s disease, to the best of our knowledge, no study has compared vestibular evoked myogenic potentials tests and auditory complaints in this context. We think this study will contribute to the diagnosis and evaluation processes of Ménière’s disease.
Material and methods
Patients
This study was designed as an analytical cross-sectional retrospective study. All described procedures were conducted following the Declaration of Helsinki. This study included 28 patients with documented medical records, otoscopic examination, pure tone audiometry (PTA), caloric testing, and both cervical-vestibular evoked myogenic potentials and ocular-vestibular evoked myogenic potentials test batteries. In this retrospective study, patients were selected based on their clinical histories, ensuring that only those who were free from acute vertigo attacks at the time of testing were included. All tests were performed by experienced audiologists at Istanbul Medipol Mega University Hospital. Of these 28 patients, based on the 2015 diagnostic criteria of the Bárány Society, 15 (53.5 per cent) were diagnosed with definite Ménière’s disease and 13 (46.5 per cent) with probable Ménière’s disease (Table 1). Patient history was carefully reviewed for relevant symptoms, and none of the included patients reported headaches or phonophobia etc. All patients were referred by otolaryngologists, and the diagnosis was confirmed in consultation with the referring specialists to ensure accurate classification.
Probable/definite Ménière’s disease criteria of the Bárány Society
Data acquisition
In this retrospective study, patient records were reviewed to gather information on the frequency and duration of vertigo/dizziness episodes, as well as fluctuating aural symptoms (hearing loss, tinnitus, and aural fullness) based on the probable Ménière’s disease and definite Ménière’s disease diagnostic criteria of the Bárány Society.Reference Lopez-Escamez, Carey, Chung, Goebel, Magnusson and Mandalà4 Otoscopic examinations were documented as having been performed on all patients. Additionally, PTA results were collected, measuring air conduction (250–8000 Hz) and bone conduction (500–4000 Hz) using TDH39 headphones (Telephonics Corporation, Farmingdale, NY) and a Radioear B71 vibrator (Middlefart, Denmark) with a clinical audiometer Interacoustics AC40 (Middelfart, Denmark).
Results of cervical-vestibular evoked myogenic potentials and ocular-vestibular evoked myogenic potentials tests were reviewed, which had been conducted using standardised protocols.Reference Taylor, Zagami, Gibson, Black, Watson and Halmagyi10, Reference Salviz, Yuce, Acar, Taylan, Yuceant and Karatas11 The presence of responses with wave formation was evaluated for all test results. For ocular-vestibular evoked myogenic potentials, wave amplitude asymmetry was analysed, while for cervical-vestibular evoked myogenic potentials, asymmetry was assessed following electromyography scaling. An asymmetry of 40 per cent or more was considered abnormal. Additionally, the records of bithermal caloric tests (Interacoustics Aqua Stim, Middelfart, Denmark) were analysed to evaluate lateral semicircular-canal function on both sides.Reference Kitano, Kitahara, Ito, Shiozaki, Wada and Yamanaka1 The caloric test order was recorded as right cold (30°C; 250 mL), left cold, right warm (44°C; 250 mL), and left warm, with each irrigation lasting 30 seconds. Nystagmus induced by the irrigation was captured using infrared cameras within the testing goggles.
Statistical analyses
The Statistical Package for the Social Sciences version 20 (SPSS Inc., Chicago, IL) was used for data analysis. The demographic characteristics and study parameters were analysed using descriptive statistics. Normality analysis was performed, and an independent samples t-test was employed for non-parametric comparisons, while the chi-square test was used to assess the association between categorical variables. A significance level of 0.05 was set for all statistical analyses.
Results
Table 2 shows the distribution of participants by gender and mean age. The mean age of the probable Ménière’s disease group was 40.9 ± 5.4 years, while the mean age of the definite Ménière’s disease group was 41.6 ± 4.1 years.
Demographic factors and acoustic complaints of participants
The results of the vestibular evoked myogenic potentials tests conducted on the probable Ménière’s disease and definite Ménière’s disease groups are presented in Table 3, which outlines the ocular-vestibular evoked myogenic potentials responses based on the affected ear in Ménière’s disease and the cervical-vestibular evoked myogenic potentials responses according to the affected ear. In both groups, ocular-vestibular evoked myogenic potentials responses were not obtained in patients whose Ménière’s disease affected the left ear. In patients whose right ear was affected, ocular-vestibular evoked myogenic potentials response was obtained in the right ear only in one patient in the definite group (Table 3). For cervical-vestibular evoked myogenic potentials responses, one patient from the definite group exhibited a response in cases where the left ear was affected. In contrast, among patients with right ear involvement, six patients from the definite group showed a response (Table 3).
Ocular-vestibular evoked myogenic potentials (oVEMP) and cervical-vestibular evoked myogenic potentials (cVEMP) test results of affected ears for patients with definite Ménière’s disease and with probable Ménière’s disease
Table 4 presents the distribution of auditory complaints based on the side affected by Ménière’s disease. In individuals with Meniere’s affecting the left ear, complaints predominantly occurred in the left ear. Similarly, for those with right ear involvement, complaints were primarily reported in the right ear.
Auditory complaints of the definite and probable group
Table 5 shows the comparison of probable Ménière’s disease and definite Ménière’s disease groups according to the asymmetry rate in vestibular evoked myogenic potentials tests and caloric test results. Table 5 also presents the comparison between the probable Ménière’s disease and definite Ménière’s disease groups based on the asymmetry rates in the vestibular evoked myogenic potentials tests and the results of the caloric test. A statistically significant difference was found between the two groups in the asymmetry rates observed in both the ocular-vestibular evoked myogenic potentials and cervical-vestibular evoked myogenic potentials tests.
Comparison of asymmetry rates of ocular-vestibular evoked myogenic potentials (oVEMP) and cervical-vestibular evoked myogenic potentials (cVEMP) results
* p <0.05
For ocular-vestibular evoked myogenic potentials, the mean asymmetry rate was 0.18 ± 0.10 in the definite group and 0.24 ± 0.10 in the probable group. For cervical-vestibular evoked myogenic potentials, the mean asymmetry rate was 0.22 ± 0.11 in the definite group and 0.35 ± 0.20 in the probable group. In the definite group, asymmetry was observed in ocular-vestibular evoked myogenic potentials in only two individuals, while three individuals exhibited asymmetry in cervical-vestibular evoked myogenic potentials. In the probable group, three individuals had asymmetry in ocular-vestibular evoked myogenic potentials, and nine individuals showed asymmetry in cervical-vestibular evoked myogenic potentials. For the caloric test, in the definite group, seven individuals exhibited right hypofunction, two had left hypofunction, four had bilateral normal responses, and two showed no response. In the probable group, four individuals displayed right hypofunction, one had left hypofunction, five had bilateral normal responses, one had bilateral hypofunction, and two showed no response.
Discussion
Ménière’s disease is a common otogenic vertigo disorder characterised by recurrent episodes of vertigo, fluctuating hearing loss, tinnitus, and a sense of fullness in the ear. In 2015, the Bárány Society classified Meniere’s syndrome into definite and probable categories. Auditory symptoms, including tinnitus, ear fullness, and hearing loss, were primarily assessed in the ear affected by Ménière’s disease, as expected. Consistent with previous findings by Lopez et al., these aural symptoms were predominantly observed in the affected ear.Reference Lopez-Escamez, Carey, Chung, Goebel, Magnusson and Mandalà4
Tinnitus and ear fullness are key diagnostic criteria for Ménière’s disease in both the definite and probable groups.Reference Goebel8 Chen et al. reported a tinnitus prevalence of 72–98 per cent and an incidence of ear fullness between 37–81 per cent.Reference Chen, Guo, Wang, Liu, Tian and Guo9 In our study, we found a tinnitus prevalence of 90 per cent in the probable group and 95.2 per cent in the definite group. For ear fullness, we observed 75 per cent in the probable group and 85.7 per cent in the definite group. These results are consistent with the findings reported by Chen et al.Reference Chen, Guo, Wang, Liu, Tian and Guo9
One of the main symptoms of Ménière’s disease is episodic vertigo lasting between 20 minutes and 12 hours.Reference Goebel8 Numerous studies have examined the relationship between objective vestibular test results and Ménière’s disease.Reference Taylor, Zagami, Gibson, Black, Watson and Halmagyi10–Reference Limviriyakul, Luangsawang, Suvansit, Prakairungthong, Thongyai and Atipas13 Vestibular tests can identify vestibular deficits and help monitor the progression of the disease. In this retrospective study, we evaluated caloric test results, as well as ocular-vestibular evoked myogenic potentials and cervical-vestibular evoked myogenic potentials test outcomes in both the probable Ménière’s disease and definite Ménière’s disease groups. In our study, caloric test results varied, with some patients showing normal responses, others exhibiting hypofunctionality, and some showing no response at all. These variations may be attributed to differences in the timing of the test, patient age, and disease progression. Additionally, no significant difference was found between the probable Ménière’s disease and definite Ménière’s disease groups in terms of caloric test results, which aligns with findings by Xie et al., who also reported no difference between these groups.Reference Xie, Zhang, Zhu, Hui, Li and Ren14
Cervical-vestibular evoked myogenic potentials and ocular-vestibular evoked myogenic potentials tests are increasingly used in the evaluation of Ménière’s disease. Studies suggest that 40–60 per cent of Ménière’s disease patients show abnormal cervical-vestibular evoked myogenic potentials responses,Reference Taylor, Zagami, Gibson, Black, Watson and Halmagyi10, Reference Salviz, Yuce, Acar, Taylan, Yuceant and Karatas11, Reference van Tilburg, Herrmann, JJ and Rauch15 while ocular-vestibular evoked myogenic potentials abnormalities, which assess the utricle, which are less common, are reported in 10–50 per cent of cases.Reference Chen, Guo, Wang, Liu, Tian and Guo9 Taha et al. described ocular-vestibular evoked myogenic potentials as the least sensitive test for Ménière’s disease.Reference Taha, Nada, Alagamy and Rahman7
Several studies have explored vestibular tests, including caloric, cervical-vestibular evoked myogenic potentials, and ocular-vestibular evoked myogenic potentials, in the Ménière’s disease population.Reference Canale, Caranzano, Lanotte, Ducati, Calamo and Albera2, Reference Egami, Ushio, Yamasoba, Yamaguchi, Murofushi and Iwasaki5, Reference Taha, Nada, Alagamy and Rahman7 Egami et al. demonstrated the diagnostic value of these tests in their study of 114 unilateral definite Ménière’s disease patients.Reference Egami, Ushio, Yamasoba, Yamaguchi, Murofushi and Iwasaki5 However, Huang et al. found no significant correlation between caloric and ocular-vestibular evoked myogenic potentials results,Reference Huang, Wang and Young6 while Taha et al. reported moderate sensitivity for cervical-vestibular evoked myogenic potentials in diagnosing definite Ménière’s disease.Reference Taha, Nada, Alagamy and Rahman7 Additionally, Jiapei et al. observed a higher degree of endolymphatic hydrops on magnetic resonance imaging in patients with definite Ménière’s disease compared to those with probable Ménière’s disease.Reference Xie, Zhang, Zhu, Hui, Li and Ren14
In our study, the asymmetry rate in the vestibular evoked myogenic potentials test was unexpectedly higher in patients with probable Ménière’s disease compared to those with definite Ménière’s disease disease. This result was surprising because more pronounced asymmetry would typically be expected in definite Ménière’s disease cases based on the observation by Jiapei et al. that the degree of endolymphatic hydrops was higher in definite Ménière’s disease patients than in probable Ménière’s disease.Reference Xie, Zhang, Zhu, Hui, Li and Ren14 Several factors may contribute to this finding. Firstly, although one would expect more impairment in definite Ménière’s disease patients, ultimately this distinction depends entirely on patients having a hearing test, and probable Ménière’s disease patients may not have had a hearing test despite experiencing more frequent episodes with more persistent effects. It is also possible that the fluctuating nature of Ménière’s disease may lead to inconsistent vestibular evoked myogenic potentials results. This may also be due to the small sample size. Further studies with larger sample sizes and longitudinal follow up are needed to explore these differences and confirm the unexpected relationship between disease stage and vestibular evoked myogenic potentials asymmetry. However, whether this difference is due to duration characteristics, frequency of attacks, or the small number of groups included should be evaluated in further studies. From a practical point of view, follow up and repetitive audiometric and vestibular tests may help diagnostic accuracy.
Additionally, Ménière’s disease is a fluctuating condition, with vestibular function potentially changing over time as patients progress through different stages of the disease. In this study, patients were not specifically stratified by the stage of Ménière’s disease. For example, in the study conducted by Sobhy et al., a comparison of vestibular tests was made according to these classifications.Reference Sobhy, Elmoazen and Abd-Elbaky16 Future research could benefit from examining individuals at various stages of Ménière’s presentation to better understand how vestibular and auditory functions evolve over the course of the disease.
• Ménière’s disease is a condition of the inner ear caused by endolymphatic hydrops, characterised by vertigo, fluctuating hearing loss, and tinnitus
• Vestibular evoked myogenic potentials and caloric testing are established methods for evaluating vestibular function in Ménière’s disease patients
• This study identified significant differences in vestibular evoked myogenic potentials asymmetry rates between probable Ménière’s disease and definite Ménière’s disease groups, with definite Ménière’s disease patients exhibiting more frequent abnormal responses
• The findings suggest that vestibular evoked myogenic potentials testing can be a valuable diagnostic tool for distinguishing between probable Ménière’s disease and definite Ménière’s disease
