Timothy C Hain

• MD
• Professor Emeritus at Northwestern University

PURPOSE OF REVIEW Vestibular testing, both at the bedside and in the laboratory, is often critical in diagnosing patients with symptoms of vertigo, dizziness, unsteadiness, and oscillopsia. This article introduces readers to core concepts, as well as recent advances, in bedside and instrumented vestibular assessments. RECENT FINDINGS Vestibular...

Objective: We aimed to describe the clinical features of the apogeotropic variant of horizontal canal benign parox-ysmal positional vertigo (HC BPPV-AG) in a cluster of patients with restrictive neck movement disorders and a new therapeutic manoeuvre for its management. Methods: In a retrospective review of cases from an ambulatory tertiary referr...

Objectives: CANVAS is an acronym for cerebellar ataxia, neuropathy and vestibular areflexia syndrome. Limited autopsy data has suggested that CANVAS is caused by a focal dorsal root ganglionopathy that damages Scarpa's (vestibular) ganglion, but spares the Spiral (hearing) ganglion. If the vestibular areflexia of CANVAS is in fact due to gangliono...

This chapter is a brief overview of migraine associated vertigo (MAV), focusing on the points most relevant to the practicing clinician. We review the definition of MAV, theories regarding its underlying pathophysiology, clinical presentation, epidemiology, findings on physical examination and oto vestibular testing, differential diagnosis, managem...

Objective To use a unique, 41‐question survey to identify patient features distinguishing cervical vertigo from vestibular causes of vertigo and vestibular migraine. Methods In this study, a unique, 41‐question survey was administered to 48 patients diagnosed with cervical vertigo (n = 16), migraine (n = 16), and vestibular vertigo (eg, unilateral...

Supplementary Table 1: Relative frequencies of reported symptom endorsement, with respect to subjects' presenting problem, n = 48

Appendix A: Dizziness Handicap Inventory‐Cervical

Head shaking nystagmus

Patients with inner ear damage associated with bilateral vestibular impairment often ask “how much damage do I have.” Although there are presently three clinical methods of measuring semicircular canal vestibular function; electronystagmography (ENG or VENG), rotatory chair and video head-impulse (VHIT) testing; none of these methods provides a met...

Bilateral vestibular weakness (BVW) is a rare cause of imbalance. Patients with BVW complain of oscillopsia. In approximately half of the patients with BVW, the cause remains undetermined; in the remainder, the most common etiology by far is gentamicin ototoxicity, followed by much rarer entities such as autoimmune inner ear disease, meningitis, bi...

Objective Our aim was to determine whether overt catch up saccades (OS) provoked by vestibular stimuli, as observed in the video head impulse test (vHIT), have comparable metrics as visually triggered horizontal saccades (VS), indicating a common saccadic brainstem generator. Methods Three groups of patients were studied: patients with neurologica...

Data sheet of raw data. (XLSX)

This chapter is a brief overview of migraine associated vertigo (MAV), focusing on the points most relevant to the practicing clinician. We review the definition of MAV, theories regarding its underlying pathophysiology, clinical presentation, epidemiology, findings on physical examination and otovestibular testing, differential diagnosis, manageme...

Dizziness and vertigo are common symptoms. About 2.5% of all primary care visits are for dizziness and about 1% are for vertigo. Dizziness and vertigo have diverse etiologies, spanning multiple organ systems. Thus, a broadly based approach to the dizzy patient is necessary, at times requiring serious and life-threatening medical problems such as ca...

Mal de débarquement syndrome (MdDS) is typified by a prolonged rocking sensation – for a month or longer – that begins immediately following a lengthy exposure to motion. The provoking motion is usually a sea voyage. About 80% of MdDS sufferers are women, and most of them are middle-aged. MdDS patients are troubled by more migraine headaches than c...

Objectives: To describe the fluctuating high velocity vestibular ocular-reflex (VOR) during the Ménière's attacks and correlate those features with pathophysiology. Patients: A patient with unilateral Ménière's disease (MD) was evaluated closely during and after acute vertigo episodes. Main outcome measures: The spontaneous nystagmus and the d...

A girl in her teens with a history of postconcussion syndrome was referred for retinal evaluation after failing her vision examination for her learner's permit for driving. She complained of progressively declining, blurred vision for 2 years. She denied floaters, flashes of light, headaches, and eye pain. The patient had a concussion 1 year prior...

This book chapter briefly reviews neurologic causes of dizziness for the practicing otolaryngologist.

Objective (Background): Vestibular evoked myogenic potentials (VEMPs) are used to evaluate function of the vestibular system. Sound evoked triceps myogenic potentials (SETMPs) have not been studied extensively and differ anatomically from sternocleidomastoid (SCM) VEMPs because the efferent pathway for SETMPs traverses the spinal cord. The aim of t...

Objective: To determine whether the amplitude of the sound evoked triceps myogenic potential (SETMP) scales with the tonic force exerted by the muscle. Study design: A prospective study of myogenic potentials was conducted in 16 normal subjects. A monaural acoustic stimulus was presented to subjects while they while they exerted varying degrees of...

Herein we discuss the recent literature concerning cervicogenic vertigo including vertigo associated with rotational vertebral artery syndrome, as well as whiplash and degenerative disturbances of the cervical spine. We conclude with a summary of progress regarding diagnostic methods for cervicogenic vertigo. Several additional single case studies...

J. Richard Ewald (1855-1921) was a German physiologist to whom we owe important insights concerning vestibular function. He is best known for 'Ewald's second law,' which implies that in persons who have lost inner ear function on one side, the remaining side should produce higher velocity nystagmus when the head is being rotated toward the remainin...

The basic anatomy and physiology of the vestibular peripheral end organ, the central processing of the vestibular system (including sensory integration), and its motor output are reviewed in this article.

Bilateral vestibular loss is a rare cause of visual disturbance (oscillopsia) and imbalance. When severe, the most common cause is iatrogenic-gentamicin ototoxicity. Bilateral loss is easily diagnosed at the bedside with the dynamic illegible E test. If this test is omitted, it can easily be misdiagnosed as a cerebellar syndrome. Treatment is large...

Cervical vertigo has long been a controversial entity and its very existence as a medical entity has advocates and opponents. Supporters of cervical vertigo claim that its actual prevalence is underestimated due to the overestimation of other diagnostic categories in clinics. Furthermore, different pathophysiological mechanisms have been attributed...

The vestibular system is a sophisticated human control system. Accurate processing of sensory input about rapid head and postural motion is critical. Not surprisingly, the body uses multiple, partially redundant sensory inputs and motor outputs, combined with a very competent central repair capability. The system as a whole can adapt to substantial...

This article presents a brief overview of migraine-associated vertigo for the practicing otolaryngologist. Discussion includes the definition of migraine-associated vertigo and its pathophysiology, clinical features, demographics, findings on physical examination, use of otologic and vestibular testing, differential diagnosis, treatment, and progno...

This chapter discussses maneuvers that are employed during physical examination to provoke nystagmus and, thereby diagnose compensated or episodic vestibular disorders. Maneuvers are divided into four broad categories: (1) those used primarily in diagnosing unilateral vestibular loss; (2) those used in diagnosing pressure sensitivity; (3) those use...

Benign paroxysmal positional vertigo (BPPV) is the most common cause of vertigo. The purpose of this systematic review was to determine whether patients diagnosed with posterior canal (PC) BPPV, based on positional testing, and treated with a particle repositioning maneuver will show the resolution of benign paroxysmal positional nystagmus (BPPN) o...

In 108 patients referred for caloric testing, head-shaking nystagmus (HSN) was noted in 37 electronystagmography (ENG) recordings. A canal paresis was found in 31 patients and a sensorineural or mixed hearing loss in one or both ears was found in 45 patients. Both HSN and canal paresis were insensitive predictors of either hearing loss or of each o...

This article describes the clinical features of anterior semicircular canal benign paroxysmal positional vertigo (AC-BPPV) and a new therapeutic maneuver for its management. Our study was a retrospective review of cases from an ambulatory tertiary referral center. Thirteen patients afflicted with positional paroxysmal vertigo exhibiting brief posit...

To determine if a sound evoked myogenic potential could be obtained from the triceps with the recording and stimulus parameters routinely used to obtain a vestibular evoked myogenic potential (VEMP) from the sternocleidomastoid. Prospective study of myogenic potentials recorded from the triceps in healthy subjects. We used a monaural acoustic stimu...

Oculomotor function has not been studied in patients with myotonic dystrophy type 2 (DM2). We report the presence of rebound nystagmus in seven of eight patients with DM2 in the absence of a structural brainstem or cerebellar lesion. The rebound nystagmus observed in these patients is very suggestive of ocular myotonia, and examination of patients...

To determine if an evoked myogenic potential could be obtained from the gastrocnemius of the leg with similar recording and stimulus parameters to those routinely used to obtain vestibular-evoked myogenic potentials from the sternocleidomastoid (SCM) of the neck. Prospective study in which we recorded evoked myogenic potentials from the gastrocnemi...

The purpose of this study was to analyze if a daily routine of self-canalith repositioning procedure (CRP) will increase the time to recurrence and reduce the rate of recurrence of benign paroxysmal positional vertigo (BPPV). Prospective study, nonrandomized control group. Outpatient clinic. Thirty-nine patients diagnosed with posterior canal BPPV...

Virtual reality (VR) training that provides optic flow stimuli and visuo-vestibular conflict has been suggested as a way to treat patients with inappropriate visual dependence (sometimes called visual vertigo even though spinning sensation is often absent). We propose a simple framework based on a hypothesis that the degree of dizziness depends on...

Previous studies have demonstrated the importance of both kinesthetic and auditory feedback for control of voice fundamental frequency (F 0). In the present study, a possible interaction between auditory feedback and kinesthetic feedback for control of voice F 0 was tested by administering local anesthetic to the vocal folds in the presence of pert...

Torsional pendular nystagmus is most commonly reported to be caused by brainstem lesions resulting in dysfunction of central oscillators that produce eye movement without an external trigger. In contrast, our case demonstrates that superior semicircular canal dehiscence (SCD) is a mechanical, peripheral vestibular etiology that should be considered...

This experiment tests the hypothesis that loading the head would increase head stability. In particular, we hypothesized that an arrangement of the head so that muscle activation is required to counteract a load would significantly increase effective neck stiffness and viscosity, which would be associated with lower peak head angular velocity follo...

Benign paroxysmal positional vertigo (BPPV) is characterized by brief periods of vertigo triggered by a change in the position of the patient's head relative to gravity. The diagnosis of BPPV is based on the patient's history and eye movements (nystagmus) evoked during two positional tests: the Dix-Hallpike maneuver and the supine with lateral head...

Perturbations in either voice pitch or loudness feedback lead to changes in a speaker's voice fundamental frequency (F0) or amplitude. Voice pitch or loudness perturbations were presented individually (either pitch or loudness shift stimuli) or simultaneously (pitch combined with loudness shift stimuli) to subjects sustaining a vowel to test the hy...

To determine if increased visual dependence can be quantified through its impact on automatic postural responses, we have measured the combined effect on the latencies and magnitudes of postural response kinematics of transient optic flow in the pitch plane with platform rotations and translations. Six healthy (29-31 yrs) and 4 visually sensitive (...

This review discusses the pharmacological treatment of dizziness, focusing particularly on the vertigo subtype of dizziness. Classes of medications useful in the treatment of vertigo include anticholinergics, antihistamines, benzodiazepines, calcium channel blockers, and dopamine blockers. These medications often have multiple actions. They may mod...

The present study tested whether subjects respond to unanticipated short perturbations in voice loudness feedback with compensatory responses in voice amplitude. The role of stimulus magnitude (+/- 1,3 vs 6 dB SPL), stimulus direction (up vs down), and the ongoing voice amplitude level (normal vs soft) were compared across compensations. Subjects r...

To determine if increased visual dependence can be quantified through its impact on automatic postural responses, we have measured the combined effect of transient optic flow in the pitch plane with platform rotations and translations on the latencies and magnitudes of postural response kinematics. Six healthy (29-31 yrs) and 4 visually sensitive (...

Pharmacologic treatment of dizziness is complex and generally not entirely satisfactory. Symptoms are caused most often by loss of function in the inner ear, which medications generally are unable to restore. Although there is a substantial armamentarium of drugs that can be used for symptomatic treatment, side effects usually are substantial. Clin...

The head-neck system has multiple degrees of freedom in both its control and response characteristics, but is often modeled as a single joint mechanical system. In this study, we have attempted to quantify the perturbation parameters that would elicit nonlinear responses in a single degree-of-freedom neuromechanical system at small amplitudes and v...

To determine if a daily routine of Brandt-Daroff exercises increases the time to recurrence and reduces the rate of recurrence of benign paroxysmal positional vertigo (BPPV). Random sample of convenience and retrospective case review. Tertiary referral center and outpatient clinic. One hundred sixteen patients diagnosed with BPPV involving the post...

Benign paroxysmal positional vertigo (BPPV) is the most commonly diagnosed vertigo syndrome. It is caused by movement of detached otoconia within the inner ear (canalithiasis) or otoconia adherent to the cupula (cupulolithiasis). A mathematical model incorporating fluid dynamics of BPPV, which results in the following insights, has been developed r...

To describe the clinical features of patients with failed vestibular nerve section that have a response to anticonvulsant medication. Retrospective case review. Ambulatory tertiary referral center. We report three patients who were afflicted with frequent brief spinning spells, or "quick spins," after vestibular neurectomy for Meniere's disease. Tr...

Recent research has found that while speaking, subjects react to perturbations in pitch of voice auditory feedback by changing their voice fundamental frequency (F0) to compensate for the perceived pitch-shift. The long response latencies (150-200 ms) suggest they may be too slow to assist in on-line control of the local pitch contour patterns asso...

Benign paroxysmal positional vertigo (BPPV) is a mechanical disorder of the vestibular system in which calcite particles called otoconia interfere with the mechanical functioning of the fluid-filled semicircular canals normally used to sense rotation. Using hydrodynamic models, we examine the two mechanisms proposed by the medical community for BPP...

In recent years, significant advances have been made in the physiology and the pharmacology of vestibular disorders. It is now possible to elaborate an approximation of the mechanisms of action of the drugs used in the symptomatic treatment of vertigo. These drugs usually have a number of different pharmacological actions and overlapping effects. T...

Recently, mechanical vibration on the neck has begun to be used to improve diagnostic sensitivity in patients who have vestibular disorders. We review results of studies of this stimulus in normal subjects and patients with vestibular lesions: the ocular responses, changes in the subjective straight ahead, and postural changes generated by the neck...

To estimate the prevalence of hypothyroidism in a population of patients with Ménière's disease (MD). Retrospective case-control study comparing the use of thyroid hormone supplements between patients with MD and controls. Outpatient neurology clinic specializing in the management of patients experiencing dizziness. Fifty patients who met the 1995...

Dizziness and vertigo are a frequent cause of medical attention; even with the most sophisticated resources we are unable to establish an etiology in many cases. However it is often possible to obtain a diagnosis if clinical criteria are used. In this paper we reviewed the frequency of presentation of the different causes of dizziness and we includ...

Benign paroxysmal positional vertigo (BPPV) is a mechanical disorder of the vestibular system where micron-size crystals abnormally drift into the semicircular canals of the inner ear that sense angular motion of the head. Sedimentation of these crystals causes sensation of motion after true head motion has stopped: vertigo results. The usual clini...

Benign Paroxysmal Positional Vertigo (BPPV) is a mechanical disorder of the vestibular system in which calcite particles called otoconia interfere with the mechanical functioning of the fluid-filled semicircular canals normally used to sense rotation. Using hydrodynamic models, we examine the two mechanisms proposed by the medical community for BPP...

While much is known about reflex and mechanical contributions to the control of head stability, little is known about predictive control. The goal of this experiment was to determine the contribution of predictive mechanisms to head stability in space, in the pitch plane, during forward trunk perturbations. Eleven standing healthy subjects had thei...

A case is presented of a 43-year-old man with bilateral lesions of the inferior colliculus (IC) due to central nervous system lymphoma. Our patient was found to have relatively normal pure-tone averages with severely reduced bilateral word recognition scores. This case illustrates that the presentation of a partial bilateral IC lesion may be of sev...

This review discusses the physiology and pharmacological treatment of vertigo and related disorders. Classes of medications useful in the treatment of vertigo include anticholinergics, antihistamines, benzodiazepines, calcium channel antagonists and dopamine receptor antagonists. These medications often have multiple actions. They may modify the in...

We aimed to investigate if there is an alteration in CD4 and CD8 T-cell populations and in CD25 and CD49d activation antigens linked to these cells during an acute attack of Ménière's disease (MD). Patients with MD who met the American Academy of Otolaryngology-Head and Neck Surgery criteria for the disease and healthy controls were enrolled in thi...

Periodic alternating nystagmus is a rare central nervous system disorder in which the eyes undergo a horizontal jerk nystagmus that periodically reverses direction. A patient with a hypoplastic cerebellum and enlarged cisterna magna exhibited transient periodic alternating nystagmus following an attack of Ménière's disease. We hypothesize that in s...

Periodic alternating nystagmus is a rare central nervous system disorder in which the eyes undergo a horizontal jerk nystagmus that periodically reverses direction. A patient with a hypoplastic cerebellum and enlarged cisterna magna exhibited transient periodic alternating nystagmus following an attack of Ménière's disease. We hypothesize that in s...

Control of the head involves somatosensory, vestibular, and visual feedback. The dynamics of these three feedback systems must be identified in order to gain a greater understanding of the head control system. We have completed one step in the development of a head control model by identifying the dynamics of the visual feedback system. A mathemati...

In order to maintain a steady voice fundamental frequency (F0), it is assumed that people compare their auditory feedback pitch with an internal (memory) or external (acoustic) referent. In the present study we examined whether the internal referent is fixed or variable by comparing voice F0 responses to incorrect auditory feedback in two timing co...

This paper describes our analysis of the complex head-neck system using a combination of experimental and modeling approaches. Dynamical analysis of head movements and EMG activation elicited by perturbation of trunk position has examined functional contributions of biomechanically and neurally generated forces in lumped systems with greatly simpli...

Changes in voice pitch auditory feedback to vocalizing subjects elicit compensatory changes in voice fundamental frequency (F0). The neural mechanisms responsible for this behavior involve the auditory and vocal-motor systems, collectively known as the audio-vocal system. Previous work [Burnett et al., J. Acoust. Soc. Am. 103, 3153-3161 (1998); Hai...

The goal of the investigation was to determine if vector analysis of nystagmus in a patient with the Tullio phenomenon could determine the source of the nystagmus. The Tullio phenomenon consists of the combination of vertigo and abnormal eye and/or head movements provoked by sound. Dehiscence of the superior semicircular canal can be found in certa...

Overview. Neurologists are frequently called upon to evaluate patients with vertigo and dizziness and, in some cases, to make sense of abnormal vestibular tests. Consequently, it is useful to have some familiarity with the methods used to test vestibular function. The vestibulo-ocular reflex (VOR) is a reflex that acts at short latency to generate...

To determine whether, in patients with benign paroxysmal positional vertigo (BPPV), the canalith repositioning procedure performed with vibration applied over the mastoid bone of the affected ear is more effective in resolving the symptoms and preventing recurrence of BPPV than the procedure performed without vibration. Retrospective case review. T...

Previous findings have shown that subjects respond to an alteration, or shift, of auditory feedback pitch with a change in voice fundamental frequency (F0). When pitch shifts exceeding 500 ms in duration were presented, subjects' averaged responses appeared to consist of both an early and a late component. The latency of the second response was lon...

Previous studies have shown that voice fundamental frequency (F0) is modified by changes in the pitch of vocal feedback and have demonstrated that the audio-vocal control system has both open- and closed-loop control properties. However, the extent to which this system operates in closed-loop fashion may have been underestimated in previous work. B...

Previous findings have shown that subjects respond to an alteration, or shift, of auditory feedback pitch with a change in voice fundamental frequency (F0). When pitch shifts exceeding 500ms in duration were presented, subjects' averaged responses appeared to consist of both an early and a late component. The latency of the second response was long...

Previous studies have shown that voice fundamental frequency (F(0)) is modified by changes in the pitch of vocal feedback and have demonstrated that the;audio-vocal control system has both open- and closed-loop control properties. However, the extent to which this system operates in closed-loop fashion may have been underestimated in previous work....

Little is known of the functionality of the vestibulo-collic reflex (VCR) and cervico-collic reflex (CCR) during head and neck movements caused by perturbations of the trunk, previously, the authors formulated mathematical expressions for these neck reflexes and incorporated them into a model of horizontal plane head movements. The formalism of thi...

To determine if the practice of T'ai Chi significantly improves balance. Twenty-two persons with mild balance disorders were studied. Five measures of balance were obtained, including 3 objective measures (moving platform posturography, Romberg testing, and reach testing) and 2 disability questionnaires (Dizziness Handicap Inventory and a modified...

The hypothesis that metronidazole can augment the ototoxicity of gentamicin was tested. Metronidazole and gentamicin are antibiotics that are used in combination to provide broad-spectrum antimicrobial coverage. It has been observed clinically that an increased ototoxic effect occurs when these agents are used in combination. Groups of guinea pigs...

Clinical features of mal de debarquement syndrome. Nearly all respondents were middle-aged women (26 of 27; mean age, 49.3 years). The duration of symptoms ranged from 6 months to 10 years (mean, 3.5 years; SD, 2.5 years). The symptoms were constant in 23 (85%) patients. Neither meclizine hydrochloride nor transdermal scopolamine was helpful. Benzo...