International guidelines for the clinical application of cervical vestibular evoked myogenic potentials: An expert consensus report

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Highlights

  • As more clinical laboratories are publishing data on the cervical vestibular evoked myogenic potential (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.

Abstract

Background

Cervical vestibular evoked myogenic potentials (cVEMPs) are electromyogram responses evoked by high-level acoustic stimuli recorded from the tonically contracting sternocleidomastoid (SCM) muscle, and have been accepted as a measure of saccular and inferior vestibular nerve function. As more laboratories are publishing cVEMP data, there is a wider range of recording methods and interpretation, which may be confusing and limit comparisons across laboratories.

Objective

To recommend minimum requirements and guidelines for the recording and interpretation of cVEMPs in the clinic and for diagnostic purposes.

Material and methods

We have avoided 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 may provide direction for accurate recording and interpretation.

Results

cVEMPs can be evoked using air-conducted (AC) sound or bone conducted (BC) vibration. The technical demands of galvanic stimulation have limited its application. For AC stimulation, the most effective frequencies are between 400 and 800 Hz below safe peak intensity levels (e.g. 140 dB peak SPL). The highpass filter should be between 5 and 30 Hz, the lowpass filter between 1000 and 3000 Hz, and the amplifier gain between 2500 and 5000. The number of sweeps averaged should be between 100 and 250 per run. Raw amplitude correction by the level of background SCM activity narrows the range of normal values. There are few publications in children with consistent results.

Conclusion

The present recommendations outline basic terminology and standard methods. Because research is ongoing, new methodologies may be included in future guidelines.

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)

  • K.J. Lee et al.

    The usefulness of rectified VEMP

    Clin Exp Otorhinolaryngol

    (2008)
  • S.M. Rosengren et al.

    Vestibular evoked myogenic potentials: past, present and future

    Clin Neurophysiol

    (2010)
  • S.M. Rosengren et al.

    Ocular and cervical vestibular evoked myogenic potentials produced by air- and bone-conducted stimuli: comparative properties and effects of age

    Clin Neurophysiol

    (2011)
  • T. Seo et al.

    Vestibular evoked myogenic potentials of undiagnosed dizziness

    Auris Nasus Larynx

    (2008)
  • K. Sheykholeslami et al.

    The effect of sternocleidomastoid electrode location on VEMP

    Auris Nasus Larynx

    (2001)
  • N.P.M. Todd et al.

    A saccular origin of frequency tuning in myogenic vestibular evoked potentials: implications for human responses to loud sounds

    Hear Res

    (2000)
  • N.J.M. Todd et al.

    Ocular vestibular evoked myogenic potentials (OVEMPs) produced by impulsive transmastoid accelerations

    Clin Neurophysiol

    (2008)
  • M. Ushio et al.

    The diagnostic value of vestibular-evoked myogenic potential in patients with vestibular schwannoma

    Clin Neurophysiol

    (2009)
  • M.S. Welgampola et al.

    Vestibulocollic reflexes: normal values and the effect of age

    Clin Neurophysiol

    (2001)
  • V.J. Wilson et al.

    Properties of central vestibular neurons fired by stimulation of the saccular nerve

    Brain Res

    (1978)
  • H.P. Wit et al.

    A simple model for the generation of the vestibular-evoked myogenic potential (VEMP)

    Clin Neurophysiol

    (2006)
  • Y.H. Young et al.

    Development of vestibular evoked myogenic potentials in early life

    Eur J Paediatr Neurol

    (2009)
  • F.W. Akin et al.

    Vestibular-evoked myogenic potentials: preliminary report

    J Am Acad Audiol

    (2001)
  • F.W. Akin et al.

    The effects of click and tone-burst stimulus parameters on the vestibular evoked myogenic potential (VEMP)

    J Am Acad Audiol

    (2003)
  • F.W. Akin et al.

    The effect of age on the vestibular evoked myogenic potential and sternocleidomastoid muscle tone electromyogram level

    Ear Hear

    (2011)
  • S.T. Aw et al.

    Click-evoked vestibulo-ocular reflex distinguishes posterior from superior canal dehiscence

    Neurology

    (2010)
  • D. Basta et al.

    Characterization of age-related changes in vestibular evoked myogenic potential

    J Vestib Res

    (2007)
  • A.P. Bath et al.

    Effect of conductive hearing loss on the vestibulo-collic reflex

    Clin Otolaryngol

    (1999)
  • K. Brantberg et al.

    Age-related changes in vestibular evoked myogenic potentials

    Audiol Neurootol

    (2007)
  • K. Brantberg et al.

    Testing vestibular-evoked myogenic potentials with 90-dB clicks is effective in the diagnosis of superior canal dehiscence syndrome

    Audiol Neurootol

    (2009)
  • A. Brodal

    Neurological anatomy

    (1981)
  • K.A. Chiappa

    Principles of evoked potentials

  • J.G. Colebatch

    Properties of rectified averaging of an evoked-type signal: theory and application to the vestibular-evoked myogenic potential

    Exp Brain Res

    (2009)
  • J.G. Colebatch

    Mapping the vestibular evoked myogenic potential (VEMP)

    J Vestib Res

    (2011)
  • J.G. Colebatch et al.

    Vestibular evoked potentials in human neck muscles before and after unilateral vestibular deafferentation

    Neurology

    (1992)
  • J.G. Colebatch et al.

    Myogenic potentials generated by a click-evoked vestibulocollic reflex

    J Neurol Neurosurg Psychiatry

    (1994)
  • J.G. Colebatch et al.

    Polarity of click and tone-evoked vestibulocollic reflexes

    Hear Res

    (2001)
  • P.D. Cremer et al.

    Posterior semicircular canal nystagmus is conjugate and its axis is parallel to that of the canal

    Neurology

    (2000)
  • I.S. Curthoys et al.

    Bone conducted vibration selectively activates irregular primary otolithic vestibular neurons in the guinea pig

    Exp Brain Res

    (2006)
  • R.R. Gacek

    Neuroanatomical correlates of vestibular function

    Ann Otol Rhinol Laryngol

    (1980)
  • G.M. Halmagyi et al.

    Tapping the head activates the vestibular system: a new use for the clinical reflex hammer

    Neurology

    (1995)
  • A. Itoh et al.

    Clinical study of vestibular-evoked myogenic potentials and auditory brainstem responses in patients with brainstem lesions

    Acta Otolaryngol

    (2001)
  • S. Iwasaki et al.

    Ocular vestibular evoked myogenic potentials in response to bone-conducted vibration of the midline forehead at Fz

    Audiol Neurotol

    (2008)
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      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. (

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