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 and Montip Tiensuwan3
1Department of Otolaryngology, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
2Department of Communication Sciences and Disorders, Ramathibodi Hospital, Mahidol University, Bangkok,
Thailand
3Department of Mathematics, Mahidol University, Bangkok, Thailand
*Corresponding author: Chanchai Jariengprasert, Department of Otolaryngology, Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand
Published: 19 May, 2017
Cite this article as: Jariengprasert C, Ruencharoen S,
Tiensuwan M. The Sensitivity and
Specificity of Vestibular Evoked
Myogenic Potential (VEMP) in the
Diagnosis of Definite Ménière’s Disease
Patients. Clin Surg. 2017; 2: 1476.
Abstract
Objective: this study was retrospectively reviewed the data to compare the sensitivity and specificity
of cervical VEMP (cVEMP) between unilateral definite Ménière’s disease (MD) patients, vestibular
migraine (VM) and control subjects.
Material and Method: all patients diagnosed as unilateral definite MD, 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 package for Microsoft was used in comparison
of the percentage and means.
Results: the unilateral definite MD group (22 males, 45 females) had mean aged 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 aged 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 aged 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 MD was significantly different from those in VM
(62.68 vs. 19.64%; X2=23.097, p=0.000) and control group (62.68 vs. 3.12%; X2=31.271, p=0.000).
The sensitivity and specificity of cVEMP in MD were 62.68 and 96.88%, respectively.
Conclusion: 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 dominant than
other vestibular test battery in 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 or either in differentiation between MD vs. VM patients, rather than a screening test
for detection of hydrops.
Keywords: Cervical vestibular evoked myogenic potential (cVEMP); Ménière’s disease;
Vestibular migraine; Sensitivity; Specificity
Introduction
Although, the diagnosis of Ménière’s Disease (MD) is based on clinical criteria [1], in some
cases laboratory investigations which have potential in the diagnosis of MD are needed. Standard
tests widely used in clinical applications are Electrocochleography (ECochG), caloric test, glycerol
and dehydrating test [2]. Their sensitivity and specificity in MD seem to be varied. The ECochG
shows sensitivity of 60% to 65% depending on electrode sites [3-6]. A significant reduction of
caloric response is found in 48% to 74% of patients with MD [7-10]. In addition, the sensitivity of
the glycerol test is reported at 50%-60% [11,12]. Each tool has limitation either in site of lesion or
unpressant side effects in the procedure. The cervical vestibular evoked myogenic potential (cVEMP)
may be useful in supporting the diagnosis of MD as an information of the saccular involvement of
the labyrinth, including the pathway from the saccule, inferior vestibular nerve, vestibular nucleus, vestibulospinal tract, through the sternocleidomastoid (SCM) muscle [13-15].
Many studies investigated cVEMP in Ménière’s patients have
shown various results [16-23]. The aim of this study was to compare
the sensitivity and specificity of the cVEMP between unilateral
definite MD patients and vestibular migraine patients and healthy
control group.
Table 1
Table 2
Table 3
Subjects and Methods
The subjects included in this study were unilateral definite
Ménière’s Disease patients (MD), Vestibular Migraine (VM) patients
and normal healthy subjects. All patients were consecutive patients
who presented to the Otolaryngology clinic at Ramathibodi Hospital
during January 2009 – December 2015. MD patients were diagnosed
using the criteria established by the AAO HNS, Balance and Hearing
Committee, 1995 [1]. VM patients were diagnosed according to the
criteria suggested by Neuhauser et al. [24].
The normal healthy control subjects were volunteer adults whom
had been tested in the previous report [25]. All subjects received a
detailed history taking and local checkup of ear, nose, and throat
fields, followed by a routine audiometry, tympanometry and cVEMP
test as described elsewhere [25].
Data analysis
SPSS package for Windows was used for data analysis in
comparison of the percentage and means. Age, gender, and Pure
Tone Average (PTA) at 500, 1000, 2000 and 3000 Hz. were collected.
The measurement of cVEMP response was considered “abnormal”
included the absent of response and the abnormal Asymmetry Ratio
(AR). The 35% cut-off was used as the upper limit of normal response
in Thai subjects [25]. The percentages of abnormal cVEMP response
in all groups were compared using Chi-square test. The sensitivity
and specificity of the cVEMP results in the MD group and the VM
group were investigated.
Table 4
Table 5
Results
In the MD group, there were 22 males and 45 females (67.17%)
having mean age of 50.62±9.41 years and mean PTA in the affected
ears (Rt. ear=37, Lt. ear=30) of 45.95±22.58 dBHL. In the VM group,
there were 5 males and 51 females (91.07%) having 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. In control group, there were 13 males
and 19 females (59.37%) having mean aged of 45.47±9.54 years and
mean PTA of 16.02±6.28 dBHL. No significant difference in age was
found among all groups (p >0.05). However, predominant female
subjects were found in VM group. PTA hearing threshold of MD was
higher than both VM and control subjects but no significant different
between VM and control groups (Table 1).
In the MD group, testing of cVEMP revealed abnormal responses
in 42 out of 67 cases showing the percentage of 62.68%. In the VM
group, testing of cVEMP revealed abnormal responses in 11 out of
56 cases showing the percentage of 19.64%. While in the control
group showed abnormal cVEMP response in one subject (3.12%).
The Chi-square test of cVEMP and disease status percentages showed
significant different at p< 0.05 (Table 2). The Chi-square test of these
percentages showed significant difference between MD vs. VM (X2-
value 23.097, p=0.000) (Table 3), between MD vs. control (X2-value
31.271, p=0.000) (Table 4), and between VM vs. control (X2-value
4.718, p=0.03) (Table 5).
The sensitivity and specificity of the cVEMP in the MD group
were 62.68%, and 96.88%, respectively. Whereas, the sensitivity and
specificity of the cVEMP in the VM group were 19.64% and 96.88%,
respectively.
Discussion
The cVEMP test was proved to detect saccular dysfunction and
many studies tried to explore abnormalities of VEMP findings in MD
and VM [16-24,26-35]. From Table 2, the percentage of abnormal
cVEMP responses found in the MD group (62.68%) was significantly
higher than those found in the VM (19.64%) and the control groups
(3.12%). (p< 0.001) The sensitivity of cVEMP for detection of MD
patient was higher than for the VM patient (62.68 vs. 19.64) while the
specificity of both groups was the same (96.88 vs. 96.88). This should
be suggested that the saccular involvement was more commonly occur
in the MD than the VM patients. This finding was similar to Egami et al. [26] study in 114 MD that cVEMP could provide appropriate
diagnosis in 50% of MD cases but giving 48.9% specificity comparing
to other vestibular disorders. In the VM group, they reported higher
percentage of abnormal cVEMP than our study (29.3%). Absent or
augmented cVEMP amplitude on affected ear was found in 54% up to
71% of MD patients [17,27,28]. On the other hand, cohort study from
Mexico found similar reduction of cVEMP amplitudes in both MD
(n=20) and VM (n=21) groups [29].
Various authors have investigated the cVEMP in MD and taken
a wide range of parameters into consideration [16-23,30-32]. Rauch
et al. [20] studied VEMP recordings from 14 normal individuals
compared to those from 34 MD subjects and found significant
difference in cVEMP amplitudes between normal ears, unaffected
MD ears and affected ears. With low frequency tone bursts, cVEMP
was presented in all normal subjects but only 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 scoring
correctly by 250 Hz. cVEMP was 80% and for click cVEMP was 55%
[23]. Taylor et al. [32] 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
differentiation between MD and VM.
Difference in percentage of abnormal cVEMP results in MD
might be from different in protocol of study using TB of 500 Hz
showed less sensitivity to 1000 Hz. (resonance frequency tuning
shift) [33] and also number of subjects and varying in disease staging.
However, when the test is abnormal, then 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 detecting of horizontal
semicircular canal function. The sensitivity of ECochG was about 60-
65% using ear tip-trode [3-6], a caloric test was about 48-74% using
25-30% interaural different criterion [7,8,10], and dehydrating agent
showed 50-60% of sensitivity [11,12]. Although the sensitivity of
cVEMP in this present study was not superior to the previous audiovestibular
tests (ECochG, caloric test, dehydrating agent), the cVEMP
was easier to perform, less uncomfortable and well tolerated by the
patients. In addition, the cVEMP test had no risk of hypotension,
dizziness, nausea, vomiting or muscle weakness in contrast to
dehydrating agents or a caloric test. From clinical observations, the
ECochG took more time to operate than the cVEMP in the same
cases. Moreover, it could be performed on patients with severe to
profound hearing loss in which the ECochG was confounded because
of its limitation. Hence, the cVEMP should be included as one of the
audio-vestibular test battery for MD or other vestibular disorders
suspected of the saccular portion involvement.
Controversy found in cVEMP investigation in MD as the
percentage of abnormal cVEMP should be greater in more advance
stage of the disease [26,31,34,35]. Moreover, saccular involvement
showed to have a greater chance of having poor hearing outcome
[35]. More important in identifying abnormal cVEMP on unaffected
ear (35%) should be alert a physician of subclinical hydrops on the
good ear [36]. Nevertheless, more researches need to be performed in
this field for better management of the patients.
This present study suggested that the cVEMP showed fairly
effect for a screening tool due to a slightly low sensitivity (62.68%)
depending on disease staging, but could be used for identifying
saccular involvement in a case of definite MD because of its high
specificity (96.88%). The results also suggested that cVEMP should be
used as a confirmative test or for staging of the disease progression or
either in differentiation between MD vs. VM patients, rather than a
screening test for detection of hydrops.
Conclusion
The cVEMP testing is a new way of assessing the saccular function in MD. The sensitivity and specificity of cVEMP in unilateral definite MD were 62.68%, and 96.88%, respectively. The sensitivity of cVEMP in MD group was significantly higher than in VM (19.64%) and the control groups (3.12%). These findings suggested more saccular involvement in the MD than the VM patients. This study revealed that the sensitivity of VEMP was not superior to ECochG, caloric and dehydrating tests. Thus, the cVEMP should be used as a confirmative test or for staging of the disease progression or either in differentiation between MD vs. VM patients, rather than a screening test for detection of hydrops.
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