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Abstract

Background: Vestibular symptoms are noted in about 40% of the individuals with otosclerosis. Vestibular-evoked myogenic potential (VEMP) is a short latency potential that assesses the functioning of otolithic organs in the vestibular system. Aim/Objectives: This systematic review explored the VEMP findings in individuals with otosclerosis. Material and Methods: Three databases, PubMed, Scopus, and Cochrane were used to perform a systematic literature review regarding VEMP findings among individuals with otosclerosis. Results: A total of 14 studies that encompasses various VEMP parameters in otosclerosis patients were included. The air-conducted vestibular-evoked myogenic potential (AC-VEMP) often had poor response rates in otosclerosis due to conductive hearing loss. Presence of bone-conducted vestibular-evoked myogenic potential (BC-VEMP) before surgery indicated intact otolithic organs in otosclerosis. Postoperatively, presence of VEMP indicated intact vestibular structures postsurgery, while its absence could indicate vestibular trauma, though other factors like stimulus intensity or efficacy of the fitted piston could influence the results. AC-VEMP responses postsurgery suggested resolution of conductive pathology or absence of lasting effects of otosclerosis. Studies show cVEMP is more affected, indicating saccular dysfunction. Conclusion: Otosclerosis affects VEMP responses, with variations observed between AC- and BC-VEMPs. While AC-VEMP responses may be affected by conductive hearing loss, BC-VEMPs offer insights into inner ear function.

Keywords

vestibular-evoked myogenic potential otosclerosis vertigo cervical VEMP ocular VEMP

Introduction

Vestibular-evoked myogenic potential (VEMP) is used to assess the functioning of the otolithic organs in the vestibular system using an acoustic stimulus. It is a short latency potential which is evoked either from the sternocleidomastoid muscle (known as cervical VEMP or cVEMP) or from the inferior oblique muscle (known as ocular VEMP or oVEMP).¹ The cVEMP assesses the integrity of sacculo-collic reflex pathway and oVEMP assess that of utriculo-ocular reflex pathway. VEMPs are typically performed in air conduction mode; however, it has significant limitations. Additionally, when exposed to air conduction stimuli, individuals with conductive hearing loss or air-bone gaps (ABG) may not elicit VEMPs. The literature reported VEMPs elicited by both air-conducted stimulus (AC-VEMP) and bone-conducted stimulus (BC-VEMP). VEMPs (cVEMP and oVEMP) is also used in cases of benign paroxysmal positional vertigo and in differential diagnosis of utricular and sacular involvement in cases of vestibular pathologies.²

Otosclerosis, also called otospongiosis, is a gradual primary bone ailment of the otic capsule. It involves abnormal localized resorption and subsequent recalcification of the endochondral layer of the temporal bone. It may lead to conductive loss, usually a progressive type which in severe cases can eventually result in a mixed hearing loss.³ There are 2 main types of otosclerosis namely the Fenestral otosclerosis and the Retrofenestral otosclerosis. Fenestral otosclerosis primarily affects the region anterior to the oval window near the fissula ante fenestram. Involvement of the stapes footplate in this condition leads to stapes fixation, resulting in conductive hearing loss. When the disease progresses beyond this region to involve the pericochlear otic capsule, it is referred to as retrofenestral otosclerosis. However, there is variability in the definitions and their use in the literature, particularly regarding whether round window involvement is considered fenestral or retrofenestral. Due to this variability, some researchers prefer to use the terms “fenestral otosclerosis” and “cochlear otosclerosis” to avoid ambiguity.⁴ Cochlear otosclerosis is characterized by progressive sensorineural hearing loss and persistent balance issues.⁵ Otosclerosis shows a higher occurrence in women compared to men and women also seem to be notably more susceptible to experiencing vestibular symptoms. Additionally, deafness escalates with age, and as deafness progresses, there is a greater degree of cochlear involvement.⁶

Vestibular symptoms have been documented in up to 40% individuals with cochlear otosclerosis.⁷ The involvement of vestibular system in patients with otosclerosis can be due to the coexistence of endolymphatic hydrops. This may occur due to extension of otosclerotic lesions into the endolymphatic duct or sac, leading to malabsorption of fluid. Another potential scenario involves the direct intrusion of otosclerotic lesions into the saccular macula or its afferent nerves.⁸ A temporal bone study found that there is an overall reduction in the number of vestibular neurons due to the otosclerotic damage to the dendritic fibers in the cribrose areas, which is responsible for the vestibular symptoms experienced in some otosclerotic patients.⁹ Otosclerosis primarily impacts the conductive system; hence, numerous studies have utilized bone-conducted stimuli to elicit VEMPs. Due to the typical balance disturbances experienced by individuals with otosclerosis, VEMP findings often indicate abnormal responses, which can vary depending on factors such as the severity of the condition and any surgical interventions performed. The aim of this systematic review is to explore the VEMP findings in patients with otosclerosis.

Methods

The present systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) 2020 guidelines.¹⁰

A literature search was conducted on VEMP findings in otosclerosis patients using PubMed, Scopus, and Cochrane databases to find relevant papers published within the past 2 decades. In total, 199 hits were obtained across all the databases. After eliminating duplicates, 176 studies were retained. Following title screening and abstract screening, 14 studies were selected for full-text review and all studies were including in the for the review. Two independent authors screened the title and abstract. The full text was extracted by the first author, and if there was any disagreement, it was resolved by discussion between coauthors.

The keywords “vestibular evoked myogenic potential,” “VEMP,” and “otosclerosis” which were combined using appropriate Boolean operators such as “AND” and “OR” was used for the search. Additional filters applied was language filters (English).

The following inclusion criteria was used:

- Articles that incorporated VEMP findings in patients with Otosclerosis;

- Articles including any type of VEMP;

- Studies in English language.

Exclusion criteria

- Articles reporting vestibular tests other than VEMP.

- Case reports & letter to editor

A customized data extraction form was created for the purpose of this review based on the aim of the review and discussion among the authors. The following information was extracted from the included studies: authors names, publication year, study design, participants, type of VEMP, outcome measures, and findings related to VEMP.

Information extracted from the studies encompassed details such as the author names, publication year, study design, participants, type of VEMP, outcome measures, and findings related to VEMP.

Quality Appraisal of the Included Study

Mixed Method Appraisal Tool (MMAT) version 2018 was used for the quality assessment of the included studies.¹¹

Results

The initial search from PubMed, Scopus, and Cochrane database yielded 199 hits. Eighteen abstracts were screened for the eligibility, total 14 article was included for the review which met the inclusion criteria. The steps followed is represented by PRISMA flowchart as depicted in Figure 1.

Figure 1.

PRISMA flowchart of the process followed for the systematic review.

A total of 14 studied which explored the VEMP findings in patients with otosclerosis was included for the final stage. The details about type of VEMP and VEMP findings in case of otosclerosis was extracted from the included study which is presented in Table 1.

Table 1.

Characteristic of Included Study.

Study ID	Study design	Participants	Type of VEMP	Outcome measures/VEMP findings	Conclusion
Lin et al¹⁷	Retrospective study	50 participants with otosclerosis. Two groups: -Grp A: with vertiginous episodes (at least 2 episodes)—27 subjects. Mean age: 50 y (12 males and 15 females). -Grp B: without vertigo—23 subjects. Mean age: 50 y (4 males and 19 females).	cVEMP-BC oVEMP-BC	The presence of each wave (N and P), Reproducibility, amplitude asymmetry, and latency of waves was analyzed. Preoperative: -Group A: 84% of ears had abnormal oVEMP test results, (25 ears—absent oVEMPs, 1 ear—augmented oVEMPs, 5 ears—reduced oVEMPs). For the cVEMP test, 51% of ears had absent responses, 49% showed normal responses. The sequence of inner ear deficits: oVEMP test (84%) followed by cVEMP test (51%). -Group B: oVEMP—normal responses in 16 ears and abnormal responses in 17 ears (52%), (11 absent responses, 1 augmented response, and 5 reduced responses). cVEMP—15 ears had normal responses, while 18 ears had abnormal responses (55%), (1 reduced response, 17 absent responses). The sequence of inner ear deficits: cVEMP test (55%) followed by oVEMP test (52%).	Patients with vertigo have more frequent abnormalities of oVEMPs to impulsive stimulation.
Saka et al⁸		25 participants with unoperated otosclerosis (9 male and 16 female)(11—unilateral involvement; 14—bilateral involvement).Two groups:D group: Disequilibrium group (10 patients).ND group: non-disequilibrium group (15 patients).	cVEMP-BC	Evaluated by the existence of P13 to N23 biphasic wave. When the biphasic wave was not detected, we considered the result to be abnormal.Preoperative:90% of patients in the D group and 13% in the ND group had abnormal results. All patients with abnormal results on BC-VEMP showed them on the lesion side.	Air-conducted cVEMP and oVEMP response rates are lower in otosclerotic patients compared to control ears. However, BC oVEMP remains unaffected by otosclerosis or stapedotomy.
Tramontani et al¹³	Prospective study	-74 patients (51 female, 23 male; mean age 38.09 y, range 23-60 y) 52 patients had B/L otosclerosis, 22 had Unilateral.-AC-VEMP was conducted in 126 ears, while both AC-VEMP and BC-VEMP were performed in 109 ears each.-A comparison was made between normal healthy individuals and the 126 ears with otosclerosis.	cVEMP: AC and BC	The reproducibility, P13 latency and N23 latency and amplitude were analyzed.Preoperative:-The response rates for AC-VEMPs and BC-VEMPs were 29.36% (32 ears) and 44.03% (48 ears), respectively.-No significant difference in the mean latencies (P1 or N1) between normal ears and ears affected by otosclerosis with recordable AC-VEMP. A significant difference noted in the mean latency of P1 in BC-VEMP.-The percentage of VEMP presence in healthy subjects was approximately 100%.	VEMP can be elicited in a small number of ears with otosclerosis. The AC-VEMP is more vulnerable to conductive hearing loss, whereas, BC-VEMP is not; however, the low presence rate of BC-VEMPs could be caused by inner ear damage.
Yang et al¹⁴	—	15 patients with otosclerosis (21 ears) without surgery.For comparison: 10 healthy subjects (2 men and 8 women; aged 26-60 y; mean, 47 y)	cVEMP: AC and BC	Mean latencies and amplitude of peaks P13 and N23 were analyzed and a comparison between AC- and BC-VEMPs were compared.Preoperative:In 21 ears, 24% showed present AC-VEMPs, while 76% displayed present BC-VEMPs. There was no significant difference in response rates, mean latencies of peaks p13 and n23, and p13 to n23 amplitude when comparing AC/BC-VEMPs between otosclerotic and healthy ears.	AC-VEMPs indicating an earlier disease stage, and absent BC-VEMPs suggesting a later stage, suggest that AC-VEMPs can complement BC-VEMPs in classifying the stage of otosclerosis.
Elmoazen et al²¹	—	-20 subjects with B/L otosclerosis.-10 adult patients with bilateral conductive otosclerosis [(40%) males and (60%) females aged between 30 and 50 y (38.0 ± 7.14 y)].-10 adult patients with bilateral mixed otosclerosis [(30%) males and more females (70%) aged between 33 and 50 y (40.20 ± 5.73 y)].	cVEMP-BCoVEMP-BC	The reproducibility, mean peak latencies of p13 and n23 waves were measured. The P13 to N23 amplitude was calculated.Preoperative:cVEMP: Lower peak-to-peak amplitudes in mixed group compared to conductive group, increased p13 latencies, and no difference in n23 latencies.oVEMP: Lower peak-to-peak amplitudes in mixed group than conductive group, with no significant differences in N1 and P1 latencies.	Peak-to-peak amplitude is suggested to be the best parameter in BC-VEMP in osteosclerotic cases. Also, bone conduction VEMP testing can help in the detection of the site of balance problems in otosclerosis cases.
Amali et al²²	—	30 otosclerotic patients (16 females/14 males; mean age was 34.37 ± 12.50 y (range, 12-46 y) and 20 healthy volunteers (12 females/8 males; 31.30 ± 6.53 y (range, 17-41 y).	cVEMP-BC	The mean peak latencies of P13 and N23 waves, the P13 to N23 amplitude was calculated; an asymmetry ratio (AR) was calculated using the following formula: AR = (Al − As)/(Al + As), where Al and As are the larger and smaller amplitudes, respectively, obtained from stimulating each ear.Preoperative:-A statistically significant 22.44% increase in P13 latency was found in the affected ears.-Lower amplitudes were noted in 8 (16.32%) otosclerotic ears.-Asymmetry ratio (AR) was assessed in 19 patients, with 6 patients (20%) showing abnormal AR.	High likelihood of vestibular dysfunction, particularly affecting the saccular pathway. Abnormal VEMP parameters correlate with disease progression. The findings indicate that cochlear otosclerosis primarily affects the saccule, followed by the utricle.
Rajati et al²⁴	Case control study	-61 subjects 31 with H/O bilateral progressive CDHL diagnosed as otosclerosis (Mean age: 37.77 ± 10.11).-30 subjects in control group (Mean age: 34.76 ± 11.65).	cVEMP-BCoVEMP-BC	The presence of each wave (N and P), amplitude asymmetry, and latency of waves was analyzed.Postoperative:-oVEMP and cVEMP were normal in less than 10% of the case group, and 85% normal result in the control group.-80.65% of the otosclerosis cases were abnormal in both VEMP tests.	The vestibular system is involved in patients with otosclerosis. The otosclerosis affects the otolithic system more severely. However, the semicircular canals also seem also seem not to be spared.
Akazawa et al²⁰	Prospective study	30 otosclerotic patients (16 females/14 males; 34.37 ± 12.50 y (range, 12-46 y) and 20 healthy volunteers (12 females/8 males; 31.30 ± 6.53 y (range, 17-41 y).	cVEMP-BCoVEMP-BC	CVEMP: P13, N23 latencies, amplitude, Asymmetric ratio of normalized amplitude.oVEMP: n10, p15 latencies, amplitude, Asymmetric ratio of normalized amplitude.Preoperative:cVEMP and oVEMP were present in all subjects; however, the amplitudes were reduced.Postoperative:-Temporary dizziness occurred in 35.0% (7 out of 20 ears) resolving within 2 to 8 days.-BC-cVEMP normal range for AR was less than 19.6%, with no deterioration in operated ears compared to opposite ears.-Delayed peak latency of BC-cVEMPs was recognized in 2 ears. For BC-oVEMPs, normal AR range was less than 33.8%, with no deterioration in operated ears and 18 out of 20 ears in the normal range.-Delayed peak latency of BC-oVEMPs was observed in 4 ears.*BC-VEMPs were examined within 3 mo postsurgery, and ARs returned to normal range after 6 mo.	Stapes surgery causes no or undetectably small otolith dysfunction from the perspective of VEMP evaluation.
Satar et al¹⁵	Retrospective study	34 participants:16 otosclerosis patients (11 females and 5 males) mean age: 42.72 ± 7.2 y.18 healthy control participants (13 females and 5 males) mean age: 32.9 ± 11.3 y.Operated, unoperated and control ears were compared.	oVEMP-AC and BCcVEMP-AC	The N23, P13 latency and P13 to N23 amplitude were measured.Preoperative:-Response rates for AC oVEMP were 42.86%.-Response rates for AC cVEMP were 30.77%.Postoperative:-Response rates for AC oVEMP were 42.11%.-Response rates for AC cVEMP were 36.84%.*Response rates of BC oVEMP for all groups and AC oVEMP, AC cVEMP for controls was 100%.	Otosclerosis is associated with lower response rates for AC ocular and cervical VEMP, regardless of whether operated on.
Singbartl et al¹⁸	Prospective study	23 patients with otosclerosis (SNHL) (18 women and 5 men; mean age, 42.4 y; range; 26-60 y)Pre versus post-surgery (3- and 6-wks postop)	cVEMP-BC	The N23 latency, P13 latency and amplitude/tonic activity ratio were measured.Preoperative:In 44% of the patients, VEMPs showed regular potentials (N23/P13) with mean latencies of P13 at 15.0 and N23 at 23.1. The remaining patients deviated from the normative data.Postoperative:In 12% of cases, VEMPs reappeared after surgery, despite being absent before. Overall, 14 ears showed regular VEMPs with mean latencies of P13 at 15.8 and N23 at 24.3, along with age-related amplitude/tonic activity ratio within normative data.	VEMPs suggest that the proximity of the saccule to the oval window niche and otosclerotic foci can lead to disorder spread to this vestibular receptor (56% in the study), although affected patients may not necessarily experience vertigo.
Stapleton et al¹²	—	50 patients with 70 ears poststapes surgery (26 otosclerotic, 4 normal) and 40 controls underwent sacculo-collic testing. All stapes surgery patients were at least 6 mo postoperative with successful closure of their otosclerotic air-bone gap.	cVEMP-AC	The reproducibility, N23 latency and P13 latency were analyzed.Unoperated ears:Otosclerotic ears had absent cVEMP.Operated ears:65 ears had absent cVEMP and 5 of them had intact response.*Controls had normal sacculo-collic response.	In patients who have undergone stapes surgery, it has no clear correlation with balance symptoms.
Winters et al¹⁹		-27 individuals with otosclerosis (14 F and 13 M subjects; mean age, 48 y; range, 29-74 y)-26 healthy individuals (13 F and 13 M subjects; mean age, 41 y; range, 24-73 y).-Divided into 4 groups: Normal ears, Otosclerotic ears, post primary surgery ear, post revision surgery ear. Comparison was made between normal ears and different ears groups.-Second part of the study, compared preoperative and post-operative testing results in 11 patients.	oVEMP-BC	The reproducibility, N23 latency and P13 latency and N23 to P13 amplitude were analyzed.Preoperative:No significant differences observed in the results among 4 groups of ears, except for the significantly shorter n1 latency at 125 dB VFL in the “postprimary stapedotomy ear” group compared to the “normal ear” and “otosclerotic ear” group at 500 Hz stimulus frequency. Additionally, all 11 patients exhibited preoperative BC-oVEMPs.Postoperative:-In 2 patients (out of 11), the BC-oVEMPs at 250 Hz stimulus frequency disappeared postoperatively, whereas the responses remained intact at 500 Hz.-The N23 to P13 amplitude was smaller, and the threshold seemed higher postoperatively compared with preoperative recordings at both 250 and 500 Hz.	No or undetectably little damage to the utricle is caused by both otosclerotic disease and stapes surgery. Thus, there is no additive value of screening with BC-oVEMPs perioperatively in otosclerotic patients.
Catalano et al²³	Prospective and case control study	-20 patients with otosclerosis (17 females and 3 males age range 33-58; mean age 44).-20 ears from 20 patients were matched with 20 healthy controls (15 females and 5 males; age range 31-59; mean age 48).*Patients with cochlear otosclerosis and preoperative vertigo were excluded.	cVEMP-AC	The latency and amplitude of the positive-negative waves P13/N23 were considered. Means of latency and amplitude of P13/N23 and evocability of cVEMPs were evaluated.Preoperative:-cVEMPs were evoked in 10/20 patients with means of P13 and N23 latencies, respectively, 15.4 and 22.9 ms, and a mean of P13/N23 amplitude of 88.6 µV.Postoperative:cVEMPs evoked in 11/20 patients 3 mo after surgery—no significant changes in latencies and amplitudes compared to preoperative measurements.-Patients experiencing dizziness or vertigo showed a significant reduction in P13/N23 amplitude postoperatively.-Temporary vestibular symptoms were reported by 7 patients, lasting less than 3 d in all cases and resolving by the 3-mo follow-up evaluation.	The reduction in cVEMPs P13/N23 amplitude indicates a probable traumatic saccular impairment in patients complaining of vestibular symptoms after surgery.
Trivelli et al¹⁶	Prospective study	41 patients with otosclerosis (32 females, 9 males).42 ears were tested (1 had bilateral stapedotomy).	cVEMP-AC and BC	The reproducibility, latency and amplitude of the P13/N23 were considered.Preoperative:AC-VEMPs were present in 9 (21.4%) ears while BC-VEMPs were recordable in 16 (38.1%) cases on the side candidate to surgery. All the patients with AC-VEMPs presented also BC-VEMPs on the otosclerotic earPostoperative:AC-VEMPs were detected in 11 (26.2%) ears with 9 having VEMPs presurgery. BC-VEMPs were recordable in 15 (35.7%) cases. All subjects with AC-VEMPs also had BC-VEMPs on the operated side.	VEMPs reduced elicitability, in otosclerosis, is likely due to conductive hearing loss and inner ear impairment.

Abbreviations: AC-VEMP, air-conducted vestibular-evoked myogenic potential; AR, asymmetric ratio; BC-VEMP, bone-conducted vestibular-evoked myogenic potential VEMP; cVEMP, cervical vestibular-evoked myogenic potential; oVEMP, ocular vestibular-evoked myogenic potential.

The methodological quality rating was done using MMAT as shown in Table 2.

Table 2.

Quality Appraisal of the Included Study.

Study ID	Is the sampling strategy relevant to address the research question?	Is the sample representative of the target population?	Are the measurements appropriate?	Is the risk of nonresponse bias low?	Is the statistical analysis appropriate to answer the research question?
Lin et al¹⁷	Yes	Can’t say	Yes	Yes	Yes
Saka et al⁸	Yes	No	Yes	Yes	Yes
Tramontani et al¹³	Yes	No	Yes	Can’t say	Yes
Yang et al¹⁴	Yes	Can’t say	Yes	Yes	Yes
Elmoazen et al²¹	Yes	Yes	Yes	Yes	Yes
Amali et al²²	Yes	Yes	Yes	Yes	Yes
Rajati et al²⁴	Yes	Yes	Yes	Can’t say	Yes
Akazawa et al²⁰	Yes	Yes	Yes	Yes	Yes
Satar et al¹⁵	Yes	Yes	Yes	Yes	Yes
Singbartl et al¹⁸	Yes	Yes	Yes	Yes	Yes
Stapleton et al¹²	Yes	Yes	Yes	Yes	Can’t say
Winters et al¹⁹	Yes	Yes	Yes	Can’t say	Yes
Catalano et al²³	Yes	Yes	Yes	Yes	Yes
Trivelli et al¹⁶	Yes	Can’t say	Yes	Yes	Yes

Discussion

Although the most common method to evaluate the vestibular function using VEMP is via air conduction (AC) mode, many studies included in this review have found that employing the AC mode may be contraindicative in case of individuals with otosclerosis. As VEMP is known to be influenced by conductive pathologies, most of the authors used bone conduction (BC) VEMP to investigate the effects of otosclerosis on vestibular structures.

Air-Conducted Cervical and Ocular VEMP Findings

As otosclerosis is typically considered a conductive pathology, the expectation initially is for the air-conducted VEMP responses to be absent preoperatively, with the assumption of their restoration postsurgery.¹² However, variations in these responses were observed in these individuals.

Tramontani et al¹³ discovered that air-conducted cVEMP response rates were lower than bone-conducted responses. They noted a significant difference in latency for bone-conducted responses but not for air-conducted ones. This led them to suggest that the presence of air-conducted cVEMP before surgery indicates a less affected inner ear compared to bone-conducted cVEMP. Preoperative recordable AC-VEMPs had significantly lower preoperative ABG, and lower means of AC and BC pure-tone averages (PTA) than those with absent AC-VEMPs. Yang elaborated on this idea, discussing how the AC cVEMP responses could offer insights into progression of the disease. The presence of AC cVEMP might suggest an earlier stage of the disease, while its absence, along with bone-conducted cVEMP, could imply a later stage.¹⁴

While comparing the operated and unoperated ears, Satar et al found that the response rates were reduced in both air-conducted oVEMP and cVEMP, regardless of surgery. Interestingly, higher cVEMP response rates were noted postsurgery when compared to the preoperated data indicating positive surgical effects. Although lower response rates of cVEMP than the oVEMP suggests a potential saccular dysfunction.¹⁵

The preoperative elicitation of AC-VEMPs is notably lower than that of BC-VEMP, possibly due to the presence of an ABG resulting from conductive hearing loss. The increase in the AC-VEMP elicitation postoperatively may primarily result from the closure of the ABG following the surgery. Absent AC-VEMPs postsurgery could imply inner ear damage.¹⁶

Bone-Conducted Cervical and Ocular VEMP Findings

Utilizing a bone conduction stimulus result in a straightforward linear acceleration at the mastoids, whereas AC stimulation does not lead to this skull acceleration but instead moves the stapes, influencing the flow of endolymph. Consequently, BC stimulation holds an advantage over AC stimulation by bypassing the structures which would otherwise affect the VEMP response in cases of otosclerosis.¹⁷

While investigating about the balance issues and bone-conducted VEMP findings, Singbartl et al¹⁸ reported 3 patients complaining of dizziness out of 23 patients with otosclerosis, and all 3 patients exhibited normal BC-VEMP results. In contrast, Yang and Young¹⁴ found 2 out of 5 patients complaining of vertigo (40%), showing absence of BC-VEMP response.

Saka’s study revealed a strong association between balance issues and abnormal BC-cVEMP findings where 90% of the individuals with balance problems showed abnormal BC-cVEMPs, suggesting a link to saccular dysfunction.⁸

Tramontani’s investigation yielded intriguing preoperative patterns, indicating that mean ABG, AC, and BC PTA did not affect BC-VEMP elicitation. Furthermore, they observed prolonged latencies of P1 and N1 in BC-VEMPs in otosclerotic ears compared to normal ones, attributing this to the persistence of BC-VEMPs in advanced otosclerosis cases. Additionally, they proposed inner ear damage due to ototoxic substances from osteosclerotic lesions as a potential cause for the relatively low occurrence rate of BC-VEMPs presurgery.¹³

Yang and Young,¹² that the mean air-bone-gap was higher in those individuals whose BC-VEMPs were absent, and when the BC PTA mean was greater than 30 dB, BC-VEMPs were found to be usually absent. Their study also studied the correlations between presence of BC-VEMP and types of patterns of conductive loss. While half of those with present BC-VEMP showed low tone type of a configuration, other half of them had an upward-sloping type of conductive hearing loss. As the disease progresses, the upward sloping type would gradually worsen and cause a flat conductive loss and about 80% of them showed absent BC-VEMP in these individuals. Thus, revealing that as the disease progresses, the response rates of BC-VEMP also decrease.

Concerning post stapes surgery outcomes, BC-VEMP response after stapes surgery was reported in 3 articles. Singbartl et al¹⁸ and Trivelli et al¹⁶ both observed the appearance of BC-VEMPs postoperatively, indicating a potential benefit of surgery on vestibular function. However, Winters et al’s¹⁹ findings suggested minimal utricle damage from stapes surgery, whereas in a study by Akazawa reported no deterioration of VEMPs on the operated ear postoperatively in any cases.²⁰

When considering which parameters of the BC-VEMP could best help in understanding the effects of otosclerosis, are most informative in understanding the effects of otosclerosis, Elmoazen et al²¹ and Amali et al²² have both suggested that peak-to-peak amplitude is the most valuable metric. They argue that abnormalities in peak-to-peak amplitude are consistently observed in affected populations, indicating that this parameter can effectively capture alterations in BC-VEMP responses associated with otosclerosis.

Catalano’s study highlighted the clinical significance of BC-cVEMPs, showing a higher frequency of abnormal BC-cVEMPs in osteosclerotic patients with vestibular symptoms. Additionally, a significant reduction in P1/N1 amplitude postoperatively hinted at a possible saccular impairment in symptomatic patients after surgery.²³

Limitations and Future Directions

This review focuses solely on studies published in English, which may introduce language bias and overlooked relevant findings published in other languages. Additionally, the exclusion of literature from nonindexed resources and case reports may have resulted in the omission of valuable insights from alternative sources. Another limitation is the lack of available studies establishing a correlation between VEMP findings and presence of symptoms. However, a promising direction for future research is suggested by a study which identified a correlation between ABG findings and the presence of bone-conducted VEMP results. Remarkably, response rates were observed to decrease when the ABG exceeded 30 dB, indicating that ABG levels could potentially influence the presence or the absence of BC-VEMP responses. Future investigations could explore this relationship further to elucidate its clinical significance.

Conclusion

In comparing the effectiveness of AC and BC modes for eliciting VEMP responses in otosclerosis patients, it was observed that preoperatively, the AC mode often yielded poor response rates due to conductive pathology, whereas the BC-VEMP proved valuable in determining otosclerosis stages before surgery. However, postoperatively, interpretations differed: a presence of BC-VEMP suggested intact vestibular structures postsurgery, while its absence could indicate vestibular trauma, though other factors like stimulus intensity or efficacy of the fitted piston could influence the results. On the other hand, AC-VEMP responses postsurgery suggested resolution of conductive pathology or absence of lasting otosclerosis effects. Regarding VEMP type, while many studies indicate cVEMP as more affected, indicating saccular dysfunction, some findings suggest comparable response rates between cVEMP and oVEMP.

Footnotes

Availability of Supporting Data

Data are embedded in the manuscript as it’s secondary research.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Ethical Approval and Consent to Participate

This study is a systematic review based on already published data, where no human participants are involved; therefore, ethical approval not applicable.

ORCID iD

Kaushlendra Kumar

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