Acta Oto-Laryngologica, 2011; 131: 945–950

ORIGINAL ARTICLE

Association of air-conducted sound oVEMP findings with cVEMP and

caloric test findings in patients with unilateral peripheral vestibular
disorders

TOSHIHISA MUROFUSHI1, HARUKA NAKAHARA1, ERIKO YOSHIMURA2 &

YUKIKO TSUDA2
1
Department of Otolaryngology, Teikyo University School of Medicine Mizonokuchi Hospital, Kawasaki and 2Yoshimura
ENT Clinic, Fujisawa, Japan

Abstract
Conclusion: This study showed that the ocular vestibular evoked myogenic potential (oVEMP) in response to
air-conducted sound (ACS) reflects functions of different parts of the vestibular labyrinth from cervical VEMP (cVEMP).
Objective: To determine whether the origin of the vestibular end organs of the oVEMP in response to ACS (500 Hz tone bursts)
is the same as that of cVEMP. Methods: Twenty patients definitively diagnosed with unilateral Meniere’s disease (MD),
6 patients with unilateral vestibular neuritis (VN), and 7 healthy subjects were enrolled. In these subjects, the oVEMP and
cVEMP to air-conducted 500 Hz tone bursts (125 dBSPL) were measured. The patients also underwent caloric tests. Results:
The MD patients did not show a significant association between their ACS oVEMP findings and ACS cVEMP findings but
there was an association of ACS oVEMP findings with caloric test findings. When the MD patients were classified into four
stages based on their hearing levels, the patients showed abnormal findings at earlier stages on ACS cVEMP than on other tests.
While all six VN patients showed abnormal findings on ACS oVEMP and caloric tests, only two patients showed abnormal
ACS cVEMPs. These findings support the hypothesis that the oVEMP in response to ACS predominantly reflects utricular
functions while ACS cVEMP reflects saccular functions.

Keywords: Meniere’s disease, vestibular neuritis, otolith, evoked responses, saccule, utricle, vestibular nerve, VEMP

Introduction Meniere’s disease (MD) is a representative disease

Vestibular evoked myogenic potentials in the cervical
muscles (cVEMP) have been used as a clinical test of the
vestibulo-collic reflex, predominantly sacculo-collic
reflex [1,2]. Recently, myogenic potentials around the
eyes (oVEMP) have also been recorded using air-
conducted sound (ACS) as well as bone-conducted
sound (BCS) [3,4]. Previous studies have suggested
that oVEMP and cVEMP reflect the functions of dif-
ferent vestibular end organs. While studies concerning
the oVEMP produced in response to BCS have been
developed [5,6], there are few studies of oVEMP in
response to ACS [4,7,8]. The clinical significance of
oVEMP in response to ACS remains unclear.
of the inner ear, while vestibular neuritis (VN) mainly
produces lesions in the vestibular nerve [9]. To clarify
whether ACS oVEMP reflects the functions of dif-
ferent components of the vestibular end organs from
ACS cVEMP, we studied patients with unilateral MD
and unilateral VN. If the current hypothesis that ACS
oVEMP reflects functions of the utricle and ACS
cVEMP reflects those of the saccule is correct,
ACS oVEMP findings and ACS cVEMP findings
should be independent of each other. Furthermore,
ACS oVEMP findings should correlate with caloric
test findings in VN patients, because both afferents
of the lateral semicircular canal and the utricle are
involved in the superior vestibular nerve. Herein we

Correspondence: Prof. Toshihisa Murofushi, Department of Otolaryngology, Teikyo University School of Medicine, Mizonokuchi Hospital, 3-8-3 Mizonokuchi
Takatsu-ku, Kawasaki 213-8507, Japan. Tel: +81 44 844 3333. Fax: +81 44 813 2257. E-mail: toshi-tky@umin.ac.jp

(Received 15 January 2011; accepted 20 March 2011)

ISSN 0001-6489 print/ISSN 1651-2251 online
2011 Informa Healthcare
DOI: 10.3109/00016489.2011.580003
946 T. Murofushi et al.
report the associations among the findings of three
neuro-otological tests in patients with MD and VN.
Material and methods
Subjects
Twenty-six patients definitively diagnosed with uni-
lateral MD or unilateral VN were enrolled into this
study. Twenty patients (2 men and 18 women) had
unilateral MD and 6 patients (5 men and 1 woman)
had unilateral VN. The patients’ ages ranged from
31 to 94 years (mean 60.8) in MD and from 41 to
77 years (mean 61.3) in VN. Patients with conductive
hearing loss were not included. The diagnoses of MD
were based on the AAO-HNS guidelines (1995) [10].
The diagnostic criteria for VN were the same as those
used in a previous study [11]; i.e. a single attack of
acute spontaneous vertigo lasting at least several
hours without accompanying auditory symptoms,
the absence of other cranial nerve or central nervous
system symptoms or signs, and severe canal paresis
(CP) on caloric testing (>50%).
We also recorded cVEMP and oVEMP of seven
healthy subjects (one man and six women) under the
same conditions as the patients. Control subjects’
ages ranged from 34 to 51 years (mean 46.5).
Informed consent was obtained from each subject
according to the Declaration of Helsinki. Ethical
approval was received from the Teikyo University
Ethics Committee.
oVEMP
For recording of oVEMP as well as cVEMP, the
Neuro-pack system (Nihon Kohden Co. Ltd, Japan)
was used. The recording electrodes were placed just
beneath the lower eye lids (active) and 2 cm below the
active electrodes (indifferent) with a ground electrode
on the nasion. As acoustic stimuli, air-conducted
500 Hz short tone bursts (125 dBSPL, rise/fall
time = 1 ms, plateau time = 2 ms) were presented
through headphones (Type DR-531, Elega Acous. Co.
Ltd, Japan). The stimulation rate was 5 Hz. Dur-
ing recording, the subject was asked to maintain an
upward gaze. The signals were amplified, bandpass-
filtered (20–2000 Hz), and 100 responses were aver-
aged. The time window for recording was –20 ms to
80 ms. To confirm the reproducibility of the results,
two runs were performed on each ear. As described in a
previous report [4], recordings obtained under the eye
contralateral to the stimulated ear were assessed. We
analyzed the first biphasic responses (nI–pI) (Figure 1).
To eliminate the effect of variations of muscle activities,
the mean background amplitude was calculated from
n23
p13
200 µV
nl 10 ms
pl
stim.
2 µV
10 ms
Figure 1. cVEMP and oVEMP of a healthy subject (51-year-old
man, left ear stimulation). The upper trace shows cVEMP on the
left sternocleidomastoid muscle, and the lower trace shows oVEMP
below the right eye.
the average rectified background activity during the
pre-stimulus period of 20 ms as previously described
for cVEMP [12]. The corrected amplitude (CA) of
the oVEMP was defined as a ratio of (amplitude of
nI–pI)/(mean background amplitude) in each run.
The corrected oVEMP amplitude (dimensionless)
was employed for interaural comparisons. For these
comparisons, the percent oVEMP asymmetry was
calculated as follows.
Percent oVEMP asymmetry = 100 |CAor–CAol|/
(CAor+CAol) (healthy subjects)
Percent oVEMP asymmetry = 100 (CAou–CAoa)/
(CAou+CAoa) (patients)
CAor(l) = corrected amplitude of nI–pI on the right
(left)
CAou(a) = corrected amplitude of nI–pI on the
unaffected (affected) side
|CAor–CAol| represented the absolute value of
CAor–CAol.
cVEMP
For recording cVEMPs, electrodes were placed on
the upper half of each sternocleidomastoid muscle
(SCM), with a reference electrode on the lateral end
of the upper sternum and a ground electrode on
the nasion. During the recording, subjects in the
supine position were instructed to raise their heads
from the pillow to contract the SCM. The other
aspects of the recording method were the same as
those for oVEMP. We analyzed the first biphasic
responses (p13–n23) (Figure 1). The mean back-
ground amplitude was also calculated from the
average rectified background activity during a pre-
stimulus period of 20 ms. The corrected oVEMP
amplitude (dimensionless) was employed for inter-
aural comparisons.
 Association of ACS oVEMP with cVEMP and caloric test
Percent cVEMP asymmetry = 100 |CAcr–CAcl|/
(CAcr+CAcl) (healthy subjects)
Percent cVEMP asymmetry = 100 (CAcu–CAca)/
(CAcu+CAca) (patients)
CAcr(l) = corrected amplitude of p13–n23 on the
right (left)
CAcu(a) = corrected amplitude of p13–n23 on the
unaffected (affected) side
|CAcr–CAcl| represented the absolute value of
CAcr–CAcl.
Caloric tests
Caloric tests were performed using electronystagmo-
graphy (ENG) by irrigating the external ear canal with
cold water while the subject was in a dark room. CP in
the caloric test was calculated using the maximum
slow phase eye velocity of caloric nystagmus.
Results
Healthy subjects
All seven control subjects showed ACS oVEMP and
ACS cVEMP responses on both sides. Both the ACS
oVEMP and ACS cVEMP showed significant corre-
lation of amplitudes (nI–pI and p13–n23) to the aver-
age background muscle activity (r = 0.695, p = 0.0045,
t test for oVEMP; r = 0.612, p = 0.018, t test for
cVEMP). Therefore, we consider that the correction of
amplitudes using the average background muscle activ-
ity is valid. The means (SDs) for healthy subjects are
summarized in Table I. Based on these findings, we set
upper limits for the normal range (mean + 2 SD),
which are also shown in Table I.
MD patients
Among the 20 patients with unilateral definite MD,
9 showed abnormal ACS oVEMPs after stimulation of
the affected side. Eight of these patients showed absence
of ACS oVEMP, and one showed decreased amplitudes.
Concerning responses on the unaffected side stimula-
tion, two of the eight patients showed absence of
responses. Concerning ACS cVEMP, 11 patients
Table I. oVEMP and cVEMP results of healthy subjects.
% oVEMP nI (oVEMP)
Parameter asymmetry (ms)
Mean 16.3 11.2
SD 14.0 1.2
Upper limit of normal 44.3 13.6
range (mean + SD)
947
showed abnormal responses (Figure 2). Nine of
the 11 patients showed absent cVEMP responses, and
2 showed prolonged p13 latencies. Concerning
responses on the unaffected side stimulation, two of
the nine patients showed absence of responses. Nine
patients showed decreased caloric responses (CP >
20%). Table II shows the correlations of findings in
one test to those in another test. Only the ACS oVEMP
findings and caloric test findings showed a significant
association (p = 0.0045, Fisher’s exact probability test).
Table III shows the association between MD dis-
ease stage and the clinical test results. The MD
patients were classified into four stages according to
hearing levels [13]. Patients with a hearing level within
25 dB (average hearing levels of 500, 1000, and
2000 Hz) were classified into stage I. Stage II was
26–40 dB, stage III was 41–70 dB, and stage IV was
higher than 70 dB. Using these criteria, nine patients
were classified into stage I, six into stage II, and five
into stage III. The patients classified into stage I
showed normal results on all three tests or abnormal
results on only one test. The patients classified into
stage II showed abnormal results on one or more
tests. The patients classified into stage III showed
abnormal results on two tests or on all three tests.
VN patients
All six patients with unilateral VN showed abnormal
ACS oVEMP responses after stimulation on the
affected side (Figure 3). Five patients showed absence
of oVEMP and one showed prolonged nI latency.
Concerning ACS cVEMP, two patients showed
abnormal (absent) cVEMPs. Canal pareses (%) of
VN patients were 59%, 65%, 74%, 75%, 78%, and
100%, respectively.
Discussion
This study demonstrated that ACS cVEMP and ACS
oVEMP are independent of each other but that
oVEMP results could have a significant association
with caloric test results in MD patients. Similar dis-
sociation between the results of these two tests was
also reported by Huang et al. [7]. Taylor et al. [14]
pI (oVEMP) % cVEMP p13 (cVEMP) n23 (cVEMP)
(ms) asymmetry (ms) (ms)
15.4 16.4 15.1 23.7
1.3 12.6 1.3 1.8
18.0 41.6 17.7 27.3
948 T. Murofushi et al.

Right ear stim. Left ear stim.

n23
cVEMP

p13
200 µV
nl nl 10 ms
oVEMP

pl 2 µV
pl stim.
stim.
10 ms

Figure 2. cVEMP and oVEMP of a left MD patient (60-year-old woman, stage II). This patient showed absence of cVEMP on left ear
stimulation, but showed normal oVEMP on both sides.

also studied AC cVEMP and AC oVEMP. While
they reported that prevalence of AC oVEMP and
AC cVEMP abnormalities were not significantly dif-
ferent, they did not mention the relationships between
the results of two tests and disease stage in each
patient. Therefore, their results are not necessarily
inconsistent with ours. In our study, the dissociation
was clearer in the VN patients.
When the relations between disease stage of MD
and test results were studied, patients in stage I did
not show any abnormal results or had an abnormal
result on only one test, ACS cVEMP or ACS oVEMP,
especially ACS cVEMP. None of the patients showed
abnormal caloric tests. The present study suggested
that ACS cVEMP could be affected in the earlier stage
of MD, while ACS oVEMP and caloric test could be
affected in the later stages.
Table II. Association between neuro-otological tests in patients
with Meniere’s disease.
cVEMP
Caloric tests are widely used as a clinical test of
lateral semicircular canal function, while VEMP are
regarded as tests of otolith organ function. The pres-
ent study suggested that the oVEMP to ACS could
reflect different functions from the cVEMP to ACS,
as indicated in previous reports [15]. To explain the
independence of the two types of VEMP tests, we
should consider the hypothesis that ACS oVEMP
predominantly reflects utricular function while ACS
cVEMP predominantly reflects saccular function.
A histopathological study showed that hydrops in
the saccule were observed in 6 of the 17 contralateral
ears (asymptomatic ears) (35%) of unilateral MD
patients while hydrops in the saccule were observed
in all the 17 ipsilateral ears (symptomatic ears) [16].
This study suggested that the saccule could be
affected at the early stage of the disease. The present
findings that ACS cVEMP tended to show abnormal
results at an earlier stage than other tests are consis-
tent with histopathological findings. Furthermore,
our results are basically consistent with those of a
preceding study into the relationships between MD

Normal Abnormal Total

Table III. Association of disease stages of Meniere’s disease with
oVEMP Normal 4 7 11
clinical test results.
Abnormal 5 4 9
Test results Stage I Stage II Stage III
Total 9 11 20
OOO 4 0 0
Caloric
OOX 0 0 0
Normal Abnormal OXO 4 2 0
oVEMP Normal 10 1 11 XOO 1 1 0
Abnormal 2 7 9 OXX 0 0 1
Total 12 8 20 XOX 0 1 2
XXO 0 0 0
Caloric
XXX 0 2 2
Normal Abnormal
Total 9 6 5
cVEMP Normal 6 3 9
O, normal result; X, abnormal result; left O(X), results of oVEMP;
Abnormal 6 5 11 middle O(X), results of cVEMP; right O(X), results of caloric tests
Total 12 8 20 (e.g. OXO = normal oVEMP and caloric response but abnormal
cVEMP).
 Association of ACS oVEMP with cVEMP and caloric test
Right ear stim.
n23
cVEMP
p13
nl
oVEMP
pl
stim.
Figure 3. cVEMP and oVEMP of a left VN patient (77-year-old man, superior vestibular neuritis). This patient showed absent oVEMP on
stimulation of the left ear, but showed normal cVEMP on both sides.
stage and ACS cVEMP findings [17]. As the utricle
and semicircular canals could be affected at a later
stage, the results of ACS oVEMP and caloric tests
might show a significant association.
The current hypothesis also explains the results in
patients with VN. It is known that VN could be
classified into three types; total, superior, and infe-
rior VN [2]. As the caloric test is a test of the superior
vestibular nerve innervating the lateral semicircular
canal, inferior VN was overlooked when the diag-
nostic criteria for VN included decreased caloric
responses. Therefore, VN in this study was com-
posed of total VN and superior VN. As utricular
afferents as well as lateral semicircular canal afferents
are in the superior vestibular nerve, the VN patients
in this study should have abnormal ACS oVEMP
irrespective of ACS cVEMP results. In fact all the
VN patients in this study showed abnormal ACS
oVEMP, while only two of the six showed abnormal
ACS cVEMP.
Of course, we need to consider alternative explana-
tions for the independence of the ACS oVEMP find-
ings and ACS cVEMP findings. Some investigators
proposed the hypothesis that ACS oVEMP are evoked
by saccular stimulation. Govender et al. [18] pro-
posed that the dissociation of ACS oVEMP findings
and ACS cVEMP findings in VN patients might be
caused by disorders of saccular afferents in the super-
ior vestibular nerve, which arise from the antero-
superior part of the saccule. While this hypothesis
could explain the dissociation in the VN patients, it is
hard to explain the dissociation in the MD patients,
because the lesion site of MD is not in the vestibular
nerve but in the inner ear. Colebatch [19] proposed
that facilitation of saccular afferents by utricular affer-
ents is required to produce ACS oVEMP. Also, this
hypothesis does not explain our present results that
many MD patients showed abnormal ACS cVEMP
but normal ACS oVEMP.
949
Left ear stim.
n23
p13
100 µV
10 ms
2 µV
stim.
10 ms
Then, we must assess the validity of the current
hypothesis that oVEMP predominantly reflects utric-
ular functions while cVEMP predominantly reflects
saccular functions from neurophysiological and neu-
roanatomical perspectives.
Utricular inputs clearly evoke eye movements [20].
According to Suzuki et al. [20], electrical stimulation
of selective utricular afferents predominantly caused
activation of the ipsilateral superior oblique muscle
and the contralateral inferior oblique muscle. Activa-
tion of the contralateral inferior oblique muscle is
likely to lead to nI potentials of oVEMP below the
eye contralateral to the stimulated ear. However, the
sacculo-ocular reflex pathway is weak and remains
unclear, although there might be some polysynaptic
reflex pathways [21]. Therefore, it is likely that ACS
oVEMP predominantly reflects utricular functions. In
studies using cats carried out by Sato et al. [22,23], it
was reported that among the vestibulo-spinal neurons
(VSNs) receiving saccular inputs, 59% descend
through the medial vestibulo-spinal tract (MVST),
which contains the cVEMP pathway [2]. Among the
VSNs receiving utricular inputs, however, only 12%
descend through the MVST. These findings suggest
that cVEMP might dominantly reflect saccular inputs.
Finally, we need to validate the sensitivity of utric-
ular afferents to ACS in mammals. Murofushi and
Curthoys [24] reported that sound-sensitive vestibu-
lar afferents exist in the caudal part of the superior
vestibular nerve as well as the inferior vestibular nerve
in guinea pigs. Although the authors suggested that
this finding resulted from the existence of saccular
afferents in the superior vestibular nerve, it could
result from sound-sensitive utricular afferents. As
the utricular macula as well as the saccular macula
is located close to the footplate of the stapes [25],
utricular afferents might respond to ACS. Sensitivity
of utricular afferents to ACS should be proven more
clearly in future studies.
950 T. Murofushi et al.
In conclusion, our study concerning the associa-
tion of ACS oVEMP findings with cVEMP and calo-
ric testing demonstrated the independence of ACS
oVEMP from ACS cVEMP. However, the ACS
oVEMP findings did show an association with find-
ings from caloric testing. These findings support the
hypothesis that findings on ACS oVEMP predomi-
nantly reflect utricular functions, while those of ACS
cVEMP predominantly reflect saccular functions.
Furthermore, we showed that this hypothesis is also
likely from both neurophysiological and neuroana-
tomical perspectives. However, we need to exclude
the possibility of contribution of the lateral semicir-
cular canal to ACS oVEMP.
Declaration of interest: The authors report no
conflicts of interest. The authors alone are responsible
for the content and writing of the paper.
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