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Sensitivity and specificity of mastoid vibration test in detection of ...

Sensitivity and specificity of mastoid vibration test in detection of ...

D. NUTI, M.

D. NUTI, M. MANDALÀTable II. Relationship between bedside vestibular tests andcaloric results.When the probability of identifying residual deficitin vestibular function was determined only by meansof bedside clinical tests, without the caloric test,15/24 patients (54%) were found to be positive withall three tests (MVT, HST, HTT), 5/28 (18%) with atleast two and 4/28 (14%) with only one. The testswere negative in 4/28 patients (14%) with an abnormalcaloric test (Table III).DiscussionParalysis Paresis SymmetricresponseCaloric test 14 12 2SN 3 (21%) 1 (8%) /MVN 13 (93%) 7 (58%) 1 * (50%)HSN 14 (100%) 4 † (33%) 2 † (100%)HTS 13 (93%) 5 (42%) /SN: spontaneous nystagmus; MVN: mastoid vibration-inducednystagmus; HSN: head shaking-induced nystagmus; HTS: headthrust sign* One patient showed reversed vibration-induced nystagmus† One patient showed reversed head shaking-induced nystagmusVestibular neuritis may cause sudden unilateral lossof vestibular function. Approximately 50% of patientsrecover this function spontaneously or aftertreatment 22 23 . While clinical and/or other signs ofdeficit persist in the remaining 50%. The caloric testis still the method of choice to detect vestibular losswith a sensitivity of 93%. Dynamic tests of peripheralvestibular deficit, such as HST and HTT, are simpleand rapid to perform and do not require specificinstruments. Mastoid vibration is another simplemethod used in the detection of unilateral vestibulardeficit.In the present study, 28 patients were selected withvestibular neuritis who still had evidence of residualvestibular deficit, as indicated by caloric weaknessand/or dynamic vestibular signs, 6 months after theacute episode. In these patients, MVN was detectedin 75%, HSN in 71%, HTS in 64%, and caloric weaknessin 93%. These results confirm those of otherstudies, namely that the vibratory test shows goodsensitivity for identifying compensated vestibularloss 2 4 5 7 . Considering only patients with vestibularneuritis, MVT sensitivity, in the literature, rangesfrom 75 to 90%, with differences probably due to thefundamental frequency of the applied stimulus (60-100 Hz) and the method used in the detection of nystagmus(Frenzel glasses or videonystagmography) 4 6 7 .The sensitivity of MVT increases with increasingseverity of the vestibular lesion. Indeed, it was possibleto induce MVN in 93% of our patients withcaloric paralysis. This finding is in keeping withthose of Michel et al. 5 and Dumas and Michel 4 whoobtained sensitivity of MVT of 100% and 96%, respectively,in patients undergoing vestibular neurectomy.When we considered patients with caloricparesis, sensitivity of MVT was only 58%.Comparison with the other two bedside vestibulartests showed that MVT was consistently more sensitivethan HTT. Compared with HST, MVT wasslightly less sensitive in patients with severe residualdeficit (caloric paralysis) and more sensitive in thosewith partial deficits. Our results are in contrast tothose of Hamann and Schuster 6 who reported a muchhigher sensitivity of MVT with respect to HST (80%vs. 35%) for identifying peripheral vestibular deficit.This difference could be due to the different patientpopulations and timing of the tests.In our patients, only one with vibration-induced nystagmusbeating towards the affected side was identified.Reversed MVN has been reported in other studieswith a higher incidence than in our study 7 . Aswith HST, identifying the affected side with MVT isnot always reliable. Though a rare possibility investibular neuritis, and without any satisfactorypathogenetic explanation, it should, nevertheless, beborne in mind as a limit of this method.The side stimulated by vibration does not seem to af-Table III. Number of patients with one or more positive bedside tests.MVN MVN MVN HSNHSN MVN HSN HTS Caloric weakness onlyHSN HTS HTSHTS15/28 3/28 1/28 1/28 2/28 1/28 1/28 4/28MVN: mastoid vibration-induced nystagmus; HSN: head shaking-induced nystagmus; HTS: head thrust sign274

MASTOID VIBRATION TESTfect the capacity to generate or modulate nystagmus.In most of our patients, MVN was elicited by stimulatingon the right and left without any significantdifference in response. In 8 patients, who showedMVN when only one mastoid was stimulated, orwhen there was an evident difference in intensity ofthe vibration-induced nystagmus, the side stimulatedwas more often the affected side (6/8 patients). Nystagmuschanging direction was not detected in any ofthese patients as occurs in other labyrinth disorders,such as Menière’s disease.We did not find MVN, in any of the 25 control subjects,that persisted for the duration of the vibrationor was repeatable. This is in keeping with the findingsof Hamann and Schuster 6 but not with those ofothers 5 8 . One reason could be that our vibratorystimulus was applied exclusively to the mastoids andthat nystagmus was observed only with Frenzelglasses and not recorded by videonystagmography.In this case, our results indicate that simpler methodsof stimulation and detection make the test more specificand less subject to false positives. We prefer toapply the stimulus to the mastoids, avoiding stimulationof the neck and vertex muscles, to simplify thetest and avoid possible interactions or interferencewith cervical afferents.The mechanism underlying MVN appears to residein the capacity of the vibratory stimulus to excitethe semicircular canals and otolithic afferents 9 10 .The effects caused by eye movements appear, therefore,to be due to direct stimulation of intactvestibular receptors on the healthy side 4 6 12 13 . SomeAuthors compare it to a simultaneous caloric testwhich exploits the peculiar stimulation. However, itis not clear why the response is not more intensewhen vibration is applied to the mastoid on thehealthy side.Table III illustrates an important practical aspect. Usingexclusively clinical tests, without the aid of thecaloric test, it was possible to identify a vestibulardeficit in 86% of patients. Thus for patients with aperforated ear drum or who refuse the caloric test,there is still a high probability of making a diagnosis.Moreover, the few cases in which MVT, HST andHTT were not useful for diagnosis, were all found tohave a partial, rather than severe, vestibular deficit.On the other hand, the negative caloric tests in twopatients who certainly still had a vestibular deficitemphasizes the need to carry out also other clinicaltests.In conclusion, the present results suggest that MVTis a rapid, comfortable and valid clinical screeningtest for detecting the presence of asymmetric vestibularfunction. We propose that it be included, togetherwith dynamic vestibular and positional tests, in thediagnostic work-up of patients with vertigo.AcknowledgementsStudy supported by Grant from University of Siena(PAR 2002). Authors are grateful to David S. Zee forreviewing the manuscript and Helen Ampt for languagecorrection.References1Lücke K. Eine Methode zur Provokation eines pathologischenNystagmus durch Vibrations-reize von 100 Hz. ZLaryngol Rhinol 1973;52:716-20.2Hamann KF. Le nystagmus de vibration: un signe de perturbationvestibulaire periferique. San Remo: Compte rendudes seances de la Societé d’Otoneurologie de languefrançaise, XXVIIe symposium, San Remo 1993, EditionIPSEN.3Michel J. Nystagmun de vibration de Hamann. J Fr Otorhinolaryngol1995;44:339-40.4Dumas G, Michel J. Valeur semiologique du test de vibrationosseux cranien. Liege: Compte rendu des seances de laSocieté d’Otoneurologie de langue française, XXXIe symposium,Liege 1997, Edition IPSEN.5Michel J, Dumas G, Lavielle JP, Characon R. Diagnosticvalue of vibration-induced nystagmus obtained by combinedvibratory stimulation applied to the neck muscles andskull of 300 vertiginous patients. Rev Laryngol Otol Rhinol2001;2:89-94.6Hamann KF, Schuster EM. Vibration induced nystagmus –a sign of unilateral vestibular deficit. J OtorhinolaryngolRelat Spec 1999;61:74-9.7Dumas G, Lavielle JP, Schrmerber S. Vibratory test andhead shaking test and caloric test: a series of 87 patients.Ann Otolaryngol Chir Cervicofac 2004;121:22-32.8Perez N. Vibration induced nystagmus in normal subjectsand in patients with dizziness. A videonystagmographystudy. Rev Laryngol Otol Rhinol 2003;2:85-90.9Young ED, Fernandez C. Responses of squirrel monkeyvestibular neurons to audio frequency sound and head vibration.Acta Otolaryngol 1977;84:352-60.10Christensen-Dalsgaard J, Narins PM. Sound and vibrationsensivity of VIIIth nerve fibres in frogs Leptodactylus abilabrisand Rana pipiens pipiens. J Comp Physiol A1993;172:653-62.11Wit HP, Bleeker JD, Mulder HH. Responses of pigeonsvestibular nerve fibers to sound and vibration with audiofrequencies.J Acoust Soc Am 1984;75:202-8.12Karlberg M, Aw S, Black R, Todd M, MacDougall H, HalamgyiM. Vibration-induced ocular torsion and nystagmusafter unilateral vestibular deafferentation. Brain2003;126,956-64.13Lackner JR. Elicitation of vestibular side effects by regionalvibration of head. Aerospace Med 1974;45:1267-72.14Roll JP, Vedel JP. Alteration of proprioceptive messages in-275

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