The Laryngoscope Lippincott Williams & Wilkins, Inc.

2006 The American Laryngological, Rhinological and Otological Society, Inc.

Improving Vestibular Evoked Myogenic Potential Reliability by using a Blood Pressure Manometer
Robby Vanspauwen, MSc; Floris L. Wuyts, PhD; Paul H. Van de Heyning, MD, PhD

Objective/Hypothesis: To improve the reliability of vestibular evoked myogenic potentials (VEMP), we propose a feedback method making use of a readily available blood pressure manometer with inflatable cuff to control the sternocleidomastoid muscle (SCM) contraction. Study Design: Prospective study. Materials and Methods: The feedback method for SCM contraction consisted of subjects pushing with their jaw against the hand-held inflated cuff to generate a specified cuff pressure. This pressure level was monitored by subject and investigator. First, we tested in a group of healthy subjects whether there was a learning or fatigue effect during four successive SCM contraction runs when making use of the feedback method. Then, we investigated the mean rectified voltage (MRV) values of the SCM. Next, we examined the hypothesis that the MRV values of the SCM contraction measured before and simultaneously with the VEMP test were equal when using this feedback method. Finally, we compared the VEMP amplitude variability in two circumstances: with and without the feedback method. Results: There was no learning or fatigue effect, and the MRV values measured before the VEMP were not significantly different from those measured during the VEMP test. The VEMP amplitude variability was significantly lower when applying the feedback method than when no feedback method was used. Conclusion: This feedback method improves significantly the VEMP amplitude reliability. Key Words: Feedback method, vestibular evoked myogenic potential, saccule, vestibular system, methodology. Laryngoscope, 116:131135, 2006

INTRODUCTION
Vestibular evoked myogenic potentials (VEMPs) serve as a diagnostic tool for saccular function. VEMPs, measured from the contracted sternocleidomastoid muscle (SCM), are inhibitory myogenic potentials that result from ipsilateral saccular stimulation by means of loud clicks or tone bursts. Currently, the outcome is confined to be binary (i.e., present or absent for a given stimulus). However, the peak latencies and the peak-topeak amplitude of the p13 to n23 waveform complex can be important parameters when determining left-right differences in the VEMP results. Because the VEMP amplitude is highly dependent on the strength of the SCM contraction, it is essential to take this tonic contraction into account to obtain a correct interpretation of left-right amplitude differences.1,2,3 A large amount of variability is caused by the fact that the SCM contraction levels are different between and even within subjects. Simultaneous monitoring of the mean rectified voltages (MRV) of the SCM contraction allows adequate maintenance of this contraction, which is required for a correct interpretation of the VEMP waveform. However, this method requires a special experimental set-up, which is usually not readily available in standard clinical settings because most commercial devices for evoked potentials do not allow simultaneous electromyography (EMG) recording when the VEMP test is performed. The authors propose a feedback method to keep the SCM contraction at a specified level based on the use of a blood pressure manometer, which is indeed available in all clinics.

From the Vestibular Function Laboratory, University Department of Otorhinolaryngology, Head and Neck Surgery, Antwerp University Hospital (R.V., F.L.W., P.H.V.D.H.), and the Department of Biomedical Physics, University of Antwerp (F.L.W.), Antwerp, Belgium. Editors Note: This Manuscript was accepted for publication September 14, 2005. Study funded by the University Department of Otorhinolaryngology, Head and Neck Surgery of Antwerp University Hospital and the University of Antwerp. Send Correspondence to Dr. Floris Wuyts, Vestibular Function Lab, Department of ENT, Antwerp University Hospital, University of Antwerp, Wilrijkstraat 10, 2650 Edegem, Belgium. E-mail: floris.wuyts@ua.ac.be DOI: 10.1097/01.mlg.0000187405.57567.ae

Study Design and Objectives

This study protocol consists of two parts. The purpose of part 1 is to verify the hypothesis that the MRV values of the contracted SCM, measured just before the VEMP test, can be considered as indicators for the tonic SCM contraction measured during the VEMP test. We first tested whether there was a significant learning or fatigue effect by comparing the MRV values of four consecutive runs (2 runs just before the VEMPs and 2 runs simultaneously with the VEMPs) when making

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use of the feedback method. Furthermore, we compared the MRV values of the SCM contraction measured before the VEMP test with the MRV values of the SCM contraction measured simultaneously with the VEMPs. The purpose of part 2 was to show that the VEMP amplitude variability is significantly lower when making use of our proposed feedback method in comparison with measurements obtained without feedback method. We compared the VEMP amplitude variability of measurements obtained with and without feedback method.

MATERIALS AND METHODS Part 1

Subjects. All subjects in this study (parts 1 and 2) had normal hearing sensitivity (20 dB hearing level, American National Standards Institute, 1996) and no history of vestibular, neurologic, or inner ear pathology. All subjects gave their informed consent, approved by the institutional review board committee of the Antwerp University Hospital. All tests were performed in a sound-proof booth. In part 1, we tested 10 healthy subjects (5 men, 5 women) ranging in age from 21 to 34 (average 26) years. Equipment and electrode location. The experiments were performed with two identical and connected auditory evoked potential systems (Nicolet Viking, Viasys Healthcare, Conshohocken, PA), equipped with EMG software. Before placing the Ag/AgCl surface electrodes (Blue Sensor, Ambu, Denmark), the skin was cleansed and scrubbed with an impedance lowering gel. The active electrodes were placed on the medial portion of the contracted SCM muscle belly, the reference electrode on the upper part of the sternum but below the attachment points of the SCM muscles, and the ground electrode on the forehead. In every subject, the distances between the active electrodes and the reference electrode was kept constant for each side. Skin impedances were less than 5 k. MRV measurement. Per side, MRV values were measured during two runs of 30 seconds just before the VEMP test as well as during two runs of 30 seconds simultaneously with the VEMP test. For each run, one average MRV value was calculated as an indicator of the SCM contraction. These averaged MRV values were used in the statistical analysis. VEMP recording and acoustic stimulation. The responses were obtained from each side separately using tone bursts of 500 Hz (95 dB nHL, rise/fall time 2 ms, plateau time 2 ms, repetition rate 5.1 Hz), which were delivered unilaterally with insert earphones (Nicolet, Viasys Healthcare, Conshohocken, PA, model TIP-300). The acoustically evoked VEMP responses were amplified, band-pass filtered (10 Hz1.5 kHz), and averaged. Each side was subjected to two runs of 150 tone bursts, which were averaged. Analysis sweep time was 100 ms. The VEMP response in this study (part 1 and 2) was only considered as being reliable if the following conditions were fulfilled: 1) the p13 and n23 peaks were reproducible in each run, and 2) the VEMP amplitude was 1.5 times greater than the residual noise in the trace preceding the p13. All results fulfilled these conditions. SCM contraction. To contract the SCM during the MRV measurement and VEMP test, a feedback method was applied based on the use of a blood pressure manometer with inflatable cuff (Welch-Allyn, Skaneateles Falls, NY). The subjects were seated in a comfortable chair with their back against the back support of the chair (the head was not positioned against a support). The cuff was inflated to a standard preset level of 20 mm Hg so that a cushion was formed. When testing the left side (i.e., measuring the MRV values or performing the VEMP test on that side), the subject had to flex the head approximately 30 degrees

forward and rotate it approximately 30 degrees to the right side, taking care not to bend the head to the right shoulder. While holding the cuff between right hand and jaw (Fig. 1), the subject pushed with his or her head against the hand-held cuff to generate a cuff pressure of 40 mm Hg. In this way, a controlled contraction in the left SCM was achieved. The subject was clearly and continuously instructed to maintain the cuff pressure at a constant level (small variations of 2 mm Hg above and below 40 mm Hg were accepted). All MRV and VEMP measurements in part 1 were performed at this cuff pressure of 40 mm Hg. Statistics. Statistical analysis in this study was performed using SPSS 12.0 (SPSS Software, SPSS, Chicago, IL). For each analysis, a significance level of 5% was adopted. Given the paired design (i.e., subjects were compared with themselves) of part 1, each statistical analysis took this repeated measures design into account by using an univariate analysis of variance with subject as a random factor.

Part 2
Subjects. In this part, we tested two groups of normal subjects. The first group (further denoted as group 1) was composed of 15 healthy subjects (7 men, 8 women) ranging in age from 21 to 37 (average 23 ) years. The second group (group 2) consisted of 12 healthy subjects (6 men, 6 women) ranging in age from 21 to 32 (average 24) years. MRV measurement. Only in group 1 was the feedback method applied. The same procedure with respect to the SCM contraction (using the feedback method) as already described in part 1 was used. Cuff pressures of 30, 40, and 50 mm Hg were applied. At each of these cuff pressures, the MRV values were recorded before the VEMP test during 1 run, separately for both sides. VEMP recording and acoustic stimulation. GROUP 1. At each cuff pressure (30, 40, and 50 mm Hg), 500 Hz tone bursts (100 dB nHL, rise/fall time 2 ms, plateau time 2 ms, repetition rate 5.1 Hz) were presented. For each side, two runs of 100 tone bursts were performed. The results of both runs were averaged, providing the final response, from which the peak-to-peak amplitude (p13n23) and absolute latencies (p13 and n23) were calculated. GROUP 2. In this group, we performed the VEMP protocol that we applied previously (i.e., without making use of a feedback

Fig. 1. Feedback method to control the contraction of the right sternocleidomastoid muscle (SCM). In this picture, the read out of the manometer is turned to the reader to clarify the testing method. When performing the test, this read out is turned to the subject.

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method). To test the left side, the subjects were asked to bend the head 30 degrees forward and rotate it 30 degrees to the right side as they had to push against the hand of the investigator, which was placed against the right jaw of the subject. This resulted in the contraction of the left SCM. The subjects were instructed to maintain a constant contraction. Tone bursts of 500 Hz were used (100 dB nHL, rise/fall time 2 ms, plateau time 2 ms, repetition rate 5.1 Hz). For each side, three runs of 100 tone bursts were presented and averaged.

RESULTS Part 1
There was no significant evolution in MRV levels during the four subsequent recordings, neither for the left SCM (F[3,27] 0.55, P .66) nor for the right SCM (F[3,27] 2.34, P .10). This indicated that there was no learning or fatigue effect. For the next analysis, we pooled for each subject the MRV values of both runs performed before the VEMP test and both runs performed simultaneously with the VEMP test (these averages are further denoted as pre and per MRV data, respectively). There was no significant difference between the pre MRV data and per MRV data, neither for the left SCM (F[1,9] 0.11, P .75) nor for the right SCM (F[1,9] 2.42, P .15). The mean difference between the pre and per MRV values per subject was 3.3 V (SD 14.9 V) for the pooled data of left and right sides. These differences were not significantly different from 0 (one sample t test: t[19] 1.001; P .33). The 95% prediction interval (mean 2 SD; mean 2 SD) of the differences between pre and per MRV values was (29; 29) V.

Fig. 2. Boxplot of difference in VEMP amplitude variability between the test protocol with (group 1) and without (group 2) feedback method for the sternocleidomastoid muscle (SCM) contraction.

Part 2
In this part, we compared the VEMP amplitude variability in both groups. The average absolute VEMP amplitude difference between the left and right side was used as the measure for repeatability. To calculate the VEMP amplitude difference of the measurements obtained with the feedback method, the data from the three applied cuff pressures were pooled. In the group tested without feedback, this absolute difference yielded 104 (SD 72, se 21) V with a range from 6 to 282 V. In the group tested with the feedback method, this value was 34 (SD 25, se 6) V, ranging from 0 to 106 V. These values were significantly different (2 samples t test: t[11.8] 3.3; P .007). The difference in VEMP amplitude variability in both groups is depicted in Figure 2.

DISCUSSION
It has already been shown that the VEMP amplitude highly depends on the strength of the SCM contraction.1,2,3 There are also several other factors, such as the stimulus intensity, muscle anatomy, subcutaneous fat layer, skin impedance, and location of active surface electrodes, that jeopardize the interpretation of the VEMP outcome.4,5 Anatomic factors causing variability cannot be ruled out, but by applying appropriate methodologies, the influence of specific factors can be reduced as much as possible. Several of these methods have already been deLaryngoscope 116: January 2006

scribed (e.g., concerning the placement of the electrodes and the stimulus settings).5,6,7,8 For a correct interpretation of left-right differences in VEMP amplitudes, the amount of SCM contraction has to be taken into account. This issue is usually only dealt with in research papers rather than in clinical papers. The main reason for this fact is that standard auditory evoked potential systems, which are used in most clinical practices to measure the VEMP response, do not usually offer the possibility to measure the MRV generated by the contracted SCM, and if they do, the equipment seldom allows simultaneous measurements of MRV and VEMP. In this study, we present an alternative method based on the use of a blood pressure manometer with inflatable cuff and an auditory evoked potential system. The advantage of this method is that the equipment (i.e., a blood pressure manometer), is standard and readily available in all clinics. The cuff method is based on the fact that a contraction of the SCM is needed to squeeze the cuff between hand and jaw. However, this is only possible when the cuff is inflated with a basal pressure of 20 mm Hg. Squeezing the cuff will generate an increase in pressure, which can be monitored on the manometer by subject and investigator. All reported cuff pressures in this paper are expressed as additional pressures with respect to this basal cuff pressure. Depending on the cuff geometry, this basal cuff pressure can be different (in our laboratory, we used 20 mm Hg). In part 1 of this study, we showed first that there was no significant training or fatigue effect, either for left or right sides, by comparing the MRV values of four subsequent measurement runs (2 runs before the VEMP test and 2 runs simultaneously with the VEMP test performed at identical cuff pressures). Based on these findings, we conclude that making use of the manometer to contract the SCM is a good method to keep the SCM contraction at a constant level throughout the test. Next, we demonstrated that there was no significant systematic difference between the average MRV values of both runs performed before the VEMP test (pre MRV value) and the average MRV values of both runs performed simultaneously with

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TABLE I. Summary of Different Steps of Feedback Method with Instructions for Subjects.
Procedure of Cuff Feedback Method Instructions for Subjects

Step 1

Step 2

Step 3 Step 4 Step 5

Subject takes place in chair with back against back support and head free to move. Electrodes are applied and connected by the investigator. Investigator shows how the subject has to bend his/her head (flexed 30 degrees forward and rotated 30 degrees to the right side to contract the left SCM). Subject assumes the desired head position. Investigator inspects that active electrode is located properly on the muscle belly of the left SCM while head of subject is rotated. Subject holds the inflated cuff between right hand and yaw. Subject pushes with head against hand-held cuff to generate a specified cuff pressure. Investigator initiates the MRV measurement while inspecting the cuff pressure. Steps 2 to 6 are repeated for the right SCM. Investigator determines which cuff pressure measured from the right SCM results in comparable values as when contracting the left SCM. Investigator initiates the VEMP recording with the previously determined cuff pressures for both sides while inspecting the cuff pressure.

Bend your head a little forward and turn it sideways Dont bend your head sideways to your shoulder

Step 6 Step 7 Step 8

Do not squeeze the cuff with your fingers. Hold the cuff with a flat hand between hand and yaw Push with your head so as to generate and maintain a pressure of 40 mm Hg* on the read out Maintain the specified cuff pressure

Step 9

Maintain the specified cuff pressure

*This pressure has to result in a clearly visible sternocleidomastoid muscle (SCM) contraction and has to be comfortable for the subject. The magnitude of the pressure is depending on the geometry of the blood pressure manometer. VEMP vestibular evoked myogenic potential; MRV mean rectified voltage.

the VEMP test (per MRV value). Therefore, when it is possible to measure the MRV values but impossible to measure these simultaneously with the VEMPs, the MRV values measured before the VEMP test can be applied as indicators for the SCM contraction performed during the VEMP test when the feedback method is applied at an identical cuff pressure. The 95% prediction interval of the differences between pre and per MRV values was (29; 29) V, which is relatively small. The small differences between pre and per MRV values were possible because we tolerated little variations of 2 mm Hg above and below the specified cuff pressure. We showed that under similar conditions (i.e., within the same person and for the same electrode placement) a relatively good correlation exists between the SCM contraction levels (represented by the MRV values) and the cuff pressures.9 In part 2, we showed that, when making use of the feedback method to control the SCM contraction, the VEMP amplitude variability is significantly lower when applying the feedback method (34 V, SD 25 V, se 6 V) than when no feedback method is used (104 V, SD 72 V, se 6 V). Therefore, it is possible to determine more reliable left-right amplitude differences in VEMP results when the feedback method is applied.

flated cuff allows for a control of the SCM contraction by means of the MRV measures. First, record, just prior to the VEMP test, the average MRV value of the SCM contraction in one side for a certain cuff pressure. Next, measure the MRV value for the SCM contracted on the opposite side. Consequently, the investigator determines which cuff pressures result in the same average MRV values for both sides. These cuff pressures, which can be different for both sides but result in identical average MRV values, are then applied during the subsequent VEMP test. This is the first goal of the feedback method. The second goal consists of the maintenance of a constant SCM contraction level throughout the VEMP recording. Both methods largely improve the VEMP reliability. The procedures of the feedback method are, together with the instructions for the subjects, summarized in Table I. 2. When no EMG equipment is available, we still propose to apply the feedback method to keep the SCM contraction constant and comparable for left and right sides. As such, the VEMP reliability will also improve.

Acknowledgments
The authors thank I. Naoemova, F. Scherf, K. Vanderkelen, W. Moeyersons, and Dr. P. ten Broecke for their assistance and technical support.

CONCLUSION
To improve the reliability of the VEMP test, which is inherently dependent on the SCM tension, we propose the following recommendations. 1. When it is possible to measure EMG values but impossible to record them simultaneously with the VEMP measurements, the blood pressure manometer with inLaryngoscope 116: January 2006

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