International guidelines for the clinical application of cervical vestibular evoked myogenic potentials: An expert consensus report
Introduction
The cervical vestibular evoked myogenic potential (cVEMP) gained international attention when Colebatch and Halmagyi (1992) described a short latency electromyogram (EMG) response evoked by high-level acoustic stimuli recorded from the tonically contracted sternocleidomastoid (SCM) muscle. The cVEMP has since gained popularity as a clinical test of saccular and inferior vestibular nerve function. In addition to loud (intense) air-conducted sound, cVEMPs can be evoked using bone conducted vibration, head taps, or galvanic stimulation. As more laboratories are publishing data on the cVEMP as a measure of vestibular function, there is a wider range of recording methods and interpretation. The variations in methodology and interpretation may be confusing to clinicians and may limit comparisons of cVEMP data across laboratories. The purpose of this article is to recommend minimum requirements and guidelines for the recording and interpretation of the cVEMP in the clinic and for diagnostic purposes. The present recommendations outline basic terminology and standard methods and advocate desirable instrumentation. Because research in this field is ongoing, new methodologies may be included in future guidelines. Therefore, this manuscript will be subject to periodic review.
We have refrained from proposing a single methodology, as clinical use of cVEMPs is evolving and questions still exist about its underlying physiology and its measurement. The development of guidelines by a panel of international experts in the field, however, may provide direction for the accurate and reliable recording and interpretation of cVEMPs.
These recommendations may require revision to keep abreast of the rapid changes in methodology, technology, and knowledge with regards to the neuroanatomy and neurophysiology of cVEMPs.
Section snippets
Terminology
To improve communication among scientists and clinicians a standardized nomenclature needs to be adopted (Celesia et al., 1993). The nomenclature in this report is derived from: (1) established use in the last two decades, especially with respect to the development of other vestibular evoked myogenic potentials, and (2) introduction of clarifications in areas where conflicting terms have been used.
Vestibular evoked myogenic potentials are electrical potential differences recorded from muscle in
Neurophysiology
Cervical vestibular evoked myogenic potentials represent a transient alteration of muscle activity. The response likely represents a short period of inhibition on a background of tonic muscle activation (Colebatch and Rothwell, 2004, Wit and Kingma, 2006). cVEMPs are employed routinely in the assessment of the functional integrity of the vestibular pathway, specifically that involving the saccule, inferior vestibular nerve, vestibular nuclear complex, medial vestibulospinal tract and the spinal
Vestibular stimulation
cVEMPs can be evoked using conventional air conducted (AC) sound (Colebatch et al., 1994), bone conducted (BC) vibration (Sheykholeslami et al., 2000) or short duration electrical (“galvanic”) stimuli (Watson and Colebatch, 1998). Of the three types of stimuli, conventional AC sound is probably the most widely used, although AC cVEMPs may be absent in patients with conductive hearing loss. All three stimuli require careful and appropriate calibration.
General statements
The cVEMP waveform is not mediated by the cochlea (Colebatch et al., 1994, Itoh et al., 2001). The presence of the response is independent of the degree of sensorineural hearing loss, and cVEMPs can be recorded in patients with profound sensorineural hearing loss (Colebatch et al., 1994, Ozeki et al., 1999, Wu and Young, 2002). Although cVEMPs may be absent in some patients with low-frequency hearing loss related to Ménière’s disease or idiopathic sudden sensorineural hearing loss (Wu and
Clinical report of results
Clinical reports should ideally contain basic information about the: (1) patient; (2) clinical status; (3) technical data; (4) normative values; (5) results; (6) interpretation.
- (1)
Patient information should include: name, age, gender and patient identification number.
- (2)
The clinical question and symptoms to be addressed should be provided.
- (3)
Technical data. The following stimulus parameters should be reported: stimulus type and level (SPL), rate of presentation, frequency of stimulus if tone is used.
- (4)
Suggested specific protocols
The following standardized protocols are suggested as the minimum requirement to obtain reliable and reproducible cVEMPs (summarized in Table 1).
The following criteria should be adhered to:
Cervical vestibular evoked myogenic potentials in pediatrics
cVEMP characteristics vary with age (Sheykholeslami et al., 2005, Picciottti et al., 2007). There are few publications, however, that have used this technique in children with consistent results, and therefore no formal guidance on its application in children based on experience can be given at this time. This is shown by the fact that there is no agreement as to when the measured parameters reach adult values, with reports ranging from 3 years of age with respect to latencies and amplitude
Acknowledgments
We would like to thank the following Societies (listed in alphabetical order) who provided important feedback with respect to the above recommended guidelines:
- (a)
American Speech Language Hearing Association
- (b)
American Academy of Audiology
- (c)
British Society of Audiology
- (d)
Japan Society for Equilibrium Research
E.P. would like to thank Ms. Maria Ellina for help in the literature search. J.G.C.’s research is supported by the National Health and Medical Research Council of Australia and the Rodney Williams and
References (87)
- et al.
Skull tap induced vestibular evoked myogenic potentials: an ipsilateral vibration response and a bilateral head acceleration response?
Clin Neurophysiol
(2008) - et al.
Recommended standards for electroretinograms and visual evoked potentials. Report of an IFCN Committee. Electroenceph
Clin Neurophysiol
(1993) - et al.
Caloric and vestibular evoked myogenic potential tests in evaluating children with benign paroxysmal vertigo
Int J Pediatr Otorhinolaryngol
(2007) - et al.
Motor unit excitability changes mediating vestibulocollic reflexes in the sternocleidomastoid muscle
Clin Neurophysiol
(2004) A critical review of the neurophysiological evidence underlying clinical vestibular testing using sound, vibration and galvanic stimuli
Clin Neurophysiol
(2010)- et al.
Vestibular neuritis has selective effects on air- and bone-conducted cervical and ocular vestibular evoked myogenic potentials
Clin Neurophysiol
(2011) - et al.
Saccular damage in patients with idiopathic sudden sensorineural hearing loss without vertigo
Otolaryngol Head Neck Surg
(2008) - et al.
Morphology of single afferents of the saccular macula in cats
Neurosci Lett
(1998) - et al.
Independent effects of simultaneous inputs from the saccule and lateral semicircular canal. Evaluation using VEMPs
Clin Neurophysiol
(2005) - et al.
Responses of primary vestibular neurons to galvanic vestibular stimulation (GVS) in the anaesthetised guinea pig
Brain Res Bull
(2004)
The usefulness of rectified VEMP
Clin Exp Otorhinolaryngol
Vestibular evoked myogenic potentials: past, present and future
Clin Neurophysiol
Ocular and cervical vestibular evoked myogenic potentials produced by air- and bone-conducted stimuli: comparative properties and effects of age
Clin Neurophysiol
Vestibular evoked myogenic potentials of undiagnosed dizziness
Auris Nasus Larynx
The effect of sternocleidomastoid electrode location on VEMP
Auris Nasus Larynx
A saccular origin of frequency tuning in myogenic vestibular evoked potentials: implications for human responses to loud sounds
Hear Res
Ocular vestibular evoked myogenic potentials (OVEMPs) produced by impulsive transmastoid accelerations
Clin Neurophysiol
The diagnostic value of vestibular-evoked myogenic potential in patients with vestibular schwannoma
Clin Neurophysiol
Vestibulocollic reflexes: normal values and the effect of age
Clin Neurophysiol
Properties of central vestibular neurons fired by stimulation of the saccular nerve
Brain Res
A simple model for the generation of the vestibular-evoked myogenic potential (VEMP)
Clin Neurophysiol
Development of vestibular evoked myogenic potentials in early life
Eur J Paediatr Neurol
Vestibular-evoked myogenic potentials: preliminary report
J Am Acad Audiol
The effects of click and tone-burst stimulus parameters on the vestibular evoked myogenic potential (VEMP)
J Am Acad Audiol
The effect of age on the vestibular evoked myogenic potential and sternocleidomastoid muscle tone electromyogram level
Ear Hear
Click-evoked vestibulo-ocular reflex distinguishes posterior from superior canal dehiscence
Neurology
Characterization of age-related changes in vestibular evoked myogenic potential
J Vestib Res
Effect of conductive hearing loss on the vestibulo-collic reflex
Clin Otolaryngol
Age-related changes in vestibular evoked myogenic potentials
Audiol Neurootol
Testing vestibular-evoked myogenic potentials with 90-dB clicks is effective in the diagnosis of superior canal dehiscence syndrome
Audiol Neurootol
Neurological anatomy
Principles of evoked potentials
Properties of rectified averaging of an evoked-type signal: theory and application to the vestibular-evoked myogenic potential
Exp Brain Res
Mapping the vestibular evoked myogenic potential (VEMP)
J Vestib Res
Vestibular evoked potentials in human neck muscles before and after unilateral vestibular deafferentation
Neurology
Myogenic potentials generated by a click-evoked vestibulocollic reflex
J Neurol Neurosurg Psychiatry
Polarity of click and tone-evoked vestibulocollic reflexes
Hear Res
Posterior semicircular canal nystagmus is conjugate and its axis is parallel to that of the canal
Neurology
Bone conducted vibration selectively activates irregular primary otolithic vestibular neurons in the guinea pig
Exp Brain Res
Neuroanatomical correlates of vestibular function
Ann Otol Rhinol Laryngol
Tapping the head activates the vestibular system: a new use for the clinical reflex hammer
Neurology
Clinical study of vestibular-evoked myogenic potentials and auditory brainstem responses in patients with brainstem lesions
Acta Otolaryngol
Ocular vestibular evoked myogenic potentials in response to bone-conducted vibration of the midline forehead at Fz
Audiol Neurotol
Cited by (162)
Republication de: Positive and negative post stapedotomy effects on cervical VEMP recordings; a STROBE analysis
2023, Annales Francaises d'Oto-Rhino-Laryngologie et de Pathologie Cervico-FacialePositive and negative post stapedotomy effects on cervical VEMP recordings; a STROBE analysis
2023, European Annals of Otorhinolaryngology, Head and Neck DiseasesVestibular function assessment in sudden hearing loss
2022, Brazilian Journal of OtorhinolaryngologyEffectiveness of galvanic vestibular evoked myogenic potential for evaluation of Meniere's disease
2022, Brazilian Journal of OtorhinolaryngologyClinical characteristics of vestibular evoked myogenic potentials in children with recurrent vertigo of childhood
2022, International Journal of Pediatric OtorhinolaryngologyCitation Excerpt :The recording epoch of the filter was set to 0–60 ms. The stimulus rate was 5.1 times per second, with more than 50 stacking times. The resistance was less than 10 Ω, and the difference between the two recording electrodes should not be too large [6]. Electrode positions: (1) cVEMP: the grounding electrode was attached to the middle of the forehead, the recording electrode was attached to the upper third of the sternocleidomastoid muscle, and the reference electrode was attached to the upper sternum. (
Inter-trial coherence as a measure of synchrony in cervical vestibular evoked myogenic potentials
2022, Journal of Neuroscience Methods