ORL 2013;75:357360

DOI: 10.1159/000357475 2014 S. Karger AG, Basel

03011569/14/0756
Received: May 8, 2013 0357$39.50/0
Accepted after revision: November 18,
2013 www.karger.com/orl
Published online: January 24, 2014

Original Paper

Evaluation of Vestibular Function

in Patients with Chronic
Suppurative Otitis Media
a a
Badr Eldin Mostafa Amr Gouda Shafik Aly M.N. El
a b a
Makhzangy Hesham Taha Heba Mahmoud Abdel Mageed
a b
Departments of Otorhinolaryngology and Audiology, Ain Shams
University, Cairo, Egypt

Key Words
Chronic suppurative otitis media Vertigo Vestibular testing Vestibular
function Videonystagmography Rotatory chair

Abstract
Objective: The objective of this study was to assess vestibular functions in patients
with chronic suppurative otitis media (CSOM) with and without sensorineural hearing
loss. Study Design: This was a prospective case study performed at a tertiary
referral university hospital. Sixty patients with CSOM were included, and patients with
a history of head trauma, diabetes, hypertension, previous ear surgery, use of
ototoxic drugs, neurological deficits and suspected fistulae were excluded. Patients
and Methods: The patients underwent basic audiological evaluation, and clinical
and instrumental vestibular evaluation. The incidence and extent of vestibular
dysfunction in patients with CSOM were analyzed. Results: A total of 42 males and
16 females with a mean age of 29.5 years were included in this study. Forty ears had
tubotym-panic disease and 19 had cholesteatoma. There were 14 ears with
sensorineural hearing loss. A positive history of vertigo was reported in 53.5% of the
cases. Rotatory chair abnormalities were found in 70% of the cases, caloric
hypofunction was found in 61.6%, and vestibular myo-genic evoked potentials were
abnormal in 25%. The only positive correlation with vestibular dysfunction was the
duration of disease. Conclusions: The vestibular system is significantly affected in
cases with CSOM. Both semicircular canals and the saccule are affected. All pa-tients
with long-standing CSOM should be evaluated for vestibular dysfunction irrespective
of their hearing levels.

2014 S. Karger AG,

Basel

Prof. Badr Eldin Mostafa

Professor of ENT-HNS, Faculty of Medicine, Ain Shams
University 34 a El Higaz Street
Heliopolis, Cairo 11351 (Egypt)
E-Mail bemostafa @
med.asu.edu.eg
 ORL 2013;75:357360 358
DOI: 10.1159/000357475 2014 S. Karger AG, Basel
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Mostafa et al.: Evaluation of Vestibular Function in Patients with Chronic Suppurative
Otitis Media

Introduction

Chronic suppurative otitis media (CSOM) can be associated with

functional damage to the inner ear resulting in sensorineural hearing loss
(SNHL) and dizziness. The same pathological factor diffusing through the
round window can lead to an altered expression of proteins causing cochlear
and vestibular damage [15]. The clinical effects of such damage are not
widely reported and are extremely variable [68]. As vertigo and instability
can negatively affect patients quality of life, assessment of vestibular
function should be part of the func-tional evaluation of patients with CSOM.
However, vestibular test abnormalities correlate poorly with a history of
dizziness and vertigo [9, 10]. The objective of this work was to assess
vestibular functions in patients with CSOM with and without SNHL.

Patients and Methods

This study included 60 patients with CSOM presenting at the Vestibular Unit of the El
Demerdash Hospital, Ain Shams University, Cairo, Egypt, between April 2009 and August
2011. The study design and intervention were approved by the Institutional Review Board.
We excluded patients with a history of head trauma, diabetes, hypertension, previous ear
surgery, use of ototoxic drugs, neurological deficits and
suspected fistulae. All patients underwent the following examinations:
Audiological examination: In pure tone audiometry and speech audiometry, SNHL was
considered if the averaged bone conduction threshold (5004,000 Hz) was more than 25 dB in
more than two frequencies
and/or a deterioration in the SD score was found.
Office vestibular tests: Spontaneous nystagmus, head impulse test (HIT), head shake test
(HST), posi-
tional and positioning tests as well as examination of stance and gait were performed.
Instrumental vestibular tests: (1) Infra-red videonystagmography (Charter v1.30, water
caloric stimu-lator NCI 480): smooth pursuit, random saccade, gaze nystagmus, optokinetic
nystagmus, and positional as well as positioning tests were conducted. A standard water
bithermal caloric test (3044 C, 60 s each) was performed after microscopic application of a
polyethylene patch. A difference of >20% determined unilateral weakness. (2) Rotatory chair
(controller model 300; Micromedical Technologies): gain, phase and symmetry were recorded
for six different frequencies (0.010.64 Hz). The test was considered abnormal if the result of at
least two frequencies fell outside the range of the normative data. (3) Computed dynamic
posturography: sensory organization tests were performed in the six standard conditions
(Neurocom Smart Equitest). (4) Vestibular evoked myogenic potential (MEB-530 4K, Neuropack;
Nihon Kohden).

Statistical Analysis
We used the Sofastat software version 1.1.0. Numerical data were analyzed according
2
to normality (Fishers exact test, test, Mann-Whitney test, Spearmans rank test).

Results

Of the included patients, 42 were males (67.4%) and 16 females (32.6%).

The age of the patients ranged from 12 to 75 years (mean age 29.56 years).
Forty-one ears had tubotym-panic disease (68.3%), and 19 had atticoantral
disease (31.7%). Vestibular symptoms were reported in 32 patients (53.5%)
with no statistical difference between ears with and without cholesteatoma
(Fishers exact test, p = 1.0, n.s.). There was a statistically significant corre-
lation between the duration of the disease and the presence of vestibular
symptoms (table 1). All office tests including HST and HIT were normal.
There were 46 ears without SNHL (76.7%) and 14 with SNHL (23.3%).
There was no statistically significant difference between ears with and
without cholesteatoma (Fishers exact test, p = 0.163, n.s.). Vestibular ocular
reflex tests were normal in all patients. Caloric
 ORL 2013;75:357360 359
DOI: 10.1159/000357475 2014 S. Karger AG, Basel
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Mostafa et al.: Evaluation of Vestibular Function in Patients with Chronic Suppurative
Otitis Media

Table 1. Duration of disease vs. positive history of vertigo

Group Median Average rank Min. Max.

Negative (n = 20) 2.0 18.6 0.0833333333333 40.0

Positive (n = 23) 6.0 24.957 0.0833333333333 33.0

The Mann-Whitney U test was used. A two-tailed p value of 0.097 was considered as statistical
trend.

Table 2. Distribution of rotatory chair results in relation to chair frequencies

Frequenc
Phase shift y
0.01 0.02 0.04 0.08 0.16 0.32 0.64

Normal 20 20 22 25 30 36 40
Positive 40 40 38 35 30 24 20

Pearsons test of linear correlation was used. A two-tailed p value of 0.002 was considered
significant.

weakness was reported in 37 patients (61.6%) but was statistically unrelated

to vertigo or SNHL. The rotatory chair testing revealed a phase defect in 42
patients (70%). The rotatory chair results were statistically related to vertigo
but not to SNHL. Furthermore, there was a reverse correlation between chair
frequency and phase defect (table 2).
There were 15 ears (25%) with delayed p13 and 12 (20%) with delayed n23
on cervical VEMP. The relationship between VEMP and vertigo or SNHL was
statistically insignificant. All patients had normal response patterns on computed
dynamic posturography. Of the 42 cases with chair abnormalities, 36 (60%) had
caloric weakness and 27 (64.2%) had associated VEMP abnormalities. Fifteen
patients had abnormalities in all three (35.7%). Of the 37 patients with caloric
weakness, 27 (72.9%) had rotatory chair abnormalities. Of the patients with
SNHL (14), 13 (92.8%) had chair abnormalities, 8 (57.1%) had caloric
abnormalities, 7 (50%) all three abnormalities and 3 (21.4%) had VEMP
abnormalities.

Discussion

The same pathologic factors affecting neural hearing in CSOM can affect
the vestibular system due to anatomical proximity [13]. Alterations in the
endolymphatic duct and sac structure were found to correspond to time-
dependent changes in the middle ear mucosa due to exposure to bacterial
toxin [11]. The current study was performed in 60 patients with CSOM to
determine the incidence of vestibular symptoms and vestibular test
abnormalities. A positive history of dizziness was reported in 32 patients
(53.5%). Only the duration of disease was associated with a complaint of
vertigo and was close to statistical significance. On the contrary, testing
revealed abnormalities in a much higher number. This may be due to gradual
vestibular compensation [9]. Rotatory chair abnormalities were reported in
70.1% of the patients, caloric weakness was found in 61.6% and VEMPs were
abnormal in 23.3% [9, 10, 12, 13]. Moreover, the relationship between
vertigo and SNHL (57.1%) was just close to statistical significance [1, 3].
 ORL 2013;75:357360 360
DOI: 10.1159/000357475 2014 S. Karger AG, Basel
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Mostafa et al.: Evaluation of Vestibular Function in Patients with Chronic Suppurative
Otitis Media

Test results suggest involvement of the semicircular canals in the low

frequency range as documented by the high-pass filter results on rotatory
chair and the abnormal calorics. A higher frequency is apparently spared as
evidenced by the normal HIT and HST results. The saccule may also be
involved as documented by the VEMP abnormalities. These results are
consistent with some form of hydrops affecting primarily the vestibular
system [11].

Conclusion

Patients with long-standing otorrhea are more vulnerable to develop

semicircular canals and saccular dysfunction independent of cochlear
damage. Vestibular function must be assessed in such patients as they may
suffer additional vestibular damage during surgery leading to
decompensation and deterioration of their quality of life as a result of vertigo
and instability.

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