Egyptian Journal of Ear, Nose, Throat and Allied Sciences (2012) 13, 113–120

Egyptian Society of Ear, Nose, Throat and Allied Sciences

Egyptian Journal of Ear, Nose, Throat and Allied

Sciences
www.ejentas.com

ORIGINAL ARTICLE

Vestibular evoked myogenic potentials (VEMPs)

with different recording procedures
Trandil H. El-Mahallawi a, Takwa A. Gabr a,*
, Soha M. Hamada b,
Shereen E. Abdel Monem b

a
Audiology Unit, Otolaryngology Head and Neck Surgery Department, Faculty of Medicine, Tanta University Hospitals,
Tanta, Egypt
b
Audiology Department, Hearing and Speech Institute, Cairo, Egypt

Received 7 April 2012; accepted 1 August 2012

Available online 8 September 2012

KEYWORDS Abstract Background: Vestibular evoked myogenic potentials (VEMPs) have become an impor-
Cervical VEMPs; tant part of the neuro-otological test battery. They are recorded from averaged electromyography
Ocular VEMPs; in response to intense auditory stimuli and are used for the assessment of the otolith function.
Combined VEMPs VEMPs have been recorded from tonically contracted cervical muscles and this approach is called
‘‘cervical’’ VEMPs (cVEMPs). They can also be recorded from extra-ocular muscles in response to
loud sound and are termed ‘‘ocular’’ VEMPs (oVEMPs). The combined VEMPs procedure can be
substituted for individual oVEMPs and cVEMPs tests.
Objectives: Comparing the results of combined (cVEMPs and oVEMPs) to individual cVEMPs
and oVEMPs in healthy subjects.
Method: Individual cVEMPs and oVEMPs then combined (cVEMPs and oVEMPs) are mea-
sured and compared with each other in 50 normal healthy adults.
Results: cVEMPs have a detectability of 100% in both individual and combined modes with
comparable latency and amplitude. While the detectability of oVEMPs was 94% in both modes
of recordings, with no significant difference as regard latencies or amplitudes.
Conclusion: Both oVEMPs and cVEMPs tests can be recorded simultaneously with high degree
of accuracy and without affecting results of each other. Combined VEMPs recording is a

* Corresponding author. Tel.: +20 1001323963; fax: +20 040

3335545.
E-mail address: takwagabr@yahoo.com (T.A. Gabr).
Peer review under responsibility of Egyptian Society of Ear, Nose,
Throat and Allied Sciences.

Production and hosting by Elsevier

2090-0740 ª 2012 Egyptian Society of Ear, Nose, Throat and Allied Sciences. Production and hosting by Elsevier B.V. All rights reserved.
http://dx.doi.org/10.1016/j.ejenta.2012.08.001
114 T.H. El-Mahallawi et al.

convenient screening tool for assessing crossed vestibule-ocular reflex and ipsilateral sacculo-collic
reflex with shortened diagnostic test time and suitable for testing children and geriatric population.
ª 2012 Egyptian Society of Ear, Nose, Throat and Allied Sciences.
Production and hosting by Elsevier B.V. All rights reserved.

1. Introduction Welgampola et al.,11 recorded oVEMPs and cVEMPs

simultaneously in healthy subjects and patients with superior
Vestibular evoked myogenic potentials (VEMPs) are short la- canal dehiscence syndrome to reduce test time. They termed
tency muscle potentials that are created when the vestibular this procedure as combined VEMPs. However, whether the
system is presented with loud sound. Evoked by acoustic, bone combined test can be substituted for individual oVEMPs or
vibration or galvanic stimulation, the VEMPs are biphasic cVEMPs test remains unclear. Chou et al.,12 reported that
potentials that represent otolith organs’ response to loud these two tests are complementary and help in clinics to better
stimulation.1 understand the status of vestibular function. Unfortunately,
These myogenic potentials may be recorded from various data about oVEMPs and combined VEMPs and their clinical
locations. The primary recording site that is used clinically is value are little which will be addressed in this work.
the sternocleidomastoid muscle (SCM) along the cervical spine
and this is called cervical VEMPs (cVEMPs). VEMPs are 2. Aims of the work
mainly composed of two components. The first component is
a positive peak occurring around 13.3 ms (P13), while the sec- This work was designed for standardization of ocular vestibu-
ond one is a negative peak occurring around 23 ms (N23) in lar-evoked myogenic potentials (oVEMPs) and the combined
the post stimulus period.2,3 cVEMPs test determines whether procedure in healthy normal hearing adults. This work was
the saccule and/or the inferior vestibular nerve and central also designed to compare the results of the combined VEMPs
connections are intact and working normally or not. The sac- with either individual oVEMPs or individual cVEMPs test in
cule, which is the lower of the two otolithic organs, has a slight healthy subjects. This work will also study the ability of using
sound sensitivity and this can be measured through VEMPs.4 the combined VEMPs as a substitute for either or both types of
VEMPs have become an important part of the neuro-otologi- individual VEMPs and thus providing more information in
cal test battery. They have been proven to be capable of detect- shorter time.
ing a variety of central pathologies such as brain stroke.5 They
can detect the delay in the vestibular system in contrast to 3. Subjects and method
other vestibular test (such as caloric testing or subjective visual
vertical) which can only detect hypofunction but not the delay.
This study included 50 randomly selected normal healthy
This is because those tests do not record short latency re-
adults. Their age ranged from 19 to 50 years with no hearing
sponses. cVEMPs test helps to determine if the saccule as well
or vestibular complaints. They were chosen from relatives of
as the inferior vestibular nerve and its central connections are
patients attending to Audiology Unit in Hearing and Speech
intact and working normally or not.
Institute or volunteers. The inclusion criteria were: bilateral
VEMPs can be recorded from the inferior extra-ocular mus-
normal peripheral hearing in the frequency range of 250–
cles of the eye. This new variation of the VEMPs is known as
8000 Hz, normal middle ear function, no history of auditory
ocular VEMPs (oVEMPs). This ocular response is considered
or vestibular complaints and absence of general health prob-
as a new diagnostic tool in neuro-otology.6,7 oVEMPs to air
lems (e.g., hypertension, diabetes mellitus and subjects with
conduction stimuli are composed of a number of potentials
neck or visual problems). Consents were obtained from all sub-
but it is the earliest negative peak, at around 10 ms, (n10 or
jects prior to contribution in the study. The research was ap-
nI) which is of great interest.6 The second potential is a posi-
proved from ethical committees in both Tanta University
tivity peaking around 15 ms and termed as pI.8 In contrast
Hospitals and Speech and Hearing Institute.
to cVEMPs recorded from the SCM muscle, the oVEMP re-
All subjects were submitted to the following: Full audiolog-
flects bilateral but predominately contralateral otolith-ocular
ical and medical history, otological examination, basic audio-
function and requires only that the patient sit quietly and fix
logical evaluation including: Pure tone audiometry and
his or her gaze on a stationary visual target.6 Moreover,
speech audiometry (Interacoustic, AC40) and immittanceme-
oVEMPs allow further assessment of central vestibular path-
try (Interacoustics, AZ26) and vestibular evoked myogenic
ways, specifically sacculo–ocular reflexes and proven to be
potentials (VEMPs) using two channel GSI Audera Evoked
more sensitive in detecting CNS demyelination as in multiple
Potentials System.
sclerosis. So, oVEMPs provide useful evaluation of central ves-
Pilot study of this work was done at Audiology Unit, Tanta
tibular function disturbances.9
University hospitals on 10 normal hearing healthy subjects.
Although each VEMPs test is relatively rapid taking less
After adjustment of the stimulating and recording parameters,
than 30 min, adding both tests into a test battery for vestibular
the work was conducted at Audiology Unit at Hearing and
function definitely prolongs the test session. Ocular and cervi-
Speech Institute. VEMPs were recorded through three proce-
cal VEMPs provide complementary information about saccu-
dures: cervical VEMPs (cVEMPs), ocular VEMPs (oVEMPs)
lar and utricular otolithic functions. So, their combined
and combined cervical and ocular VEMPs (combined
recording allows the crossed vestibulo-ocular reflex and ipsilat-
VEMPs). In the three procedures, VEMPs were recorded using
eral sacculo-collic reflex to be determined.10
500 Hz short tone burst of 7 ms duration (1 ms rise and fall
Vestibular evoked myogenic potentials (VEMPs) with different recording procedures
time and 5 ms plateau) and 8/s. repetition rate. The filter set-
ting was 100–3000 Hz. The stimulus was delivered at 95
dBnHL via insert earphones. The total number of sweeps
was 320 sweeps with a time window of 0–75 ms. The stimulus
and recording parameters were the same for individual and
combined modes.
Electrode montage was done according to Chou et al.12
Nine electrodes were used for recording VEMPs. The ground
electrode was placed over the forehead. Active electrodes were
placed on the middle third of the contracted SCM muscle on
each side (for recoding cVEMPs). Other active electrodes were
placed just inferior to each eye, about 1 cm below the centre of
the lower eyelid (for recoding oVEMPs). The reference elec-
trodes were placed at the mid-clavicle point (in case of
cVEMPs) while the other two reference electrodes were posi-
tioned about 1–2 cm below the corresponding active ones be-
low each eye (in case of oVEMPs).
In case of individual cVEMPs, the subjects were asked to
rotate their head to the opposite side of recording with flexing
their head approximately 30 forward to contract the SCM
muscle. In case of individual oVEMPs, the subject was in-
structed to look upward at distant target from the eyes. Re-
sponses from each infra-ocular muscle were recorded
separately. When the combined oVEMPs and cVEMPs test
was conducted, subjects were instructed to rotate their heads
away from the stimulated side and gaze upward.
VEMPs were recorded from the cervical (cVEMPs) and in-
fra-ocular muscles (oVEMPs) in two modes, individual and
combined. In individual mode (for either cVEMPs or
oVEMPs), the responses were recorded from the ipsilateral
side in cVEMPs and contralateral side in oVEMPs. In each
electrode position, both modes were compared with each
other.
For all recorded traces (in individual cVEMPs or oVEMPs
and combined VEMPs), the detectability of each wave was cal-
culated followed by identification of the positive and negative
peaks according to their latencies. This was followed by mea-
suring base to peak amplitude of each wave. Inter-aural ampli-
tude ratios (IARs) were also calculated for each type of
VEMPs recording. The test time required for recording either
individual ocular or cervical was 5 min for each test (10 min
for both). The combined VEMPs recording was almost equal
to either individual cervical or ocular procedure recording
(5 min only).
4. Statistical analysis
Student’s t-test was used for comparing mean and standard
deviation (SD) of both latencies and amplitudes of individual
and combined cervical VEMPs. The same was also done as re-
gards ocular VEMPs and interaural amplitude ratio (IAR).
Pearson correlation was done to find any relation between
VEMPs latencies and amplitudes in both modes.
5. Results
This study included 50 normal hearing adults. Their age ran-
ged from 18 to 40 years with a mean of 31.8 ± 8.9 years.
They were 17 males and 33 females. They were collected from
relatives of patients and volunteers attending audiology clinic
at Hearing and Speech Institute. All subjects had bilateral
115
normal peripheral hearing in the frequency range of 250–
8000 Hz and bilateral excellent speech discrimination scores
as well as normal middle ear function and normal ipsilateral
and contralateral acoustic reflex thresholds. All subjects had
no history of otologic, vestibular or neck problems. The
exclusion criteria included subjects with hearing loss, dizzi-
ness, neck pain or systemic disease (such as diabetes mellitus,
hypertension).
The detectability of waves P13 and N23 of cVEMPs in indi-
vidual and combined mode of cVEMPs was 100%. While, the
delectability of waves nI and pI of oVEMPs in both individual
and combined modes was 94% as oVEMPs were absent bilat-
erally in 3 subjects (see Fig. 1).
Results of this work showed no significant difference be-
tween right and left ears for individual cVEMPs and combined
cVEMPs and for individual oVEMPs and combined oVEMPs
as regards latencies and amplitude of P13 and N23 recorded
from both sides when compared with each other. So, in each
mode of recording, the data from right and left ears were gath-
ered and compared across different modes. Comparing the
latencies of P13 and N23 of both modes of cVEMPs revealed
no significant difference (P > 0.05). As regards the ampli-
tudes, comparing the amplitudes of P13 and N23 of both
modes of cVEMPs revealed no significant difference (P >
0.05) (Table 1 and Figs. 2 and 3).
In case of oVEMPs, comparing the latencies of nI and pI of
both modes of oVEMPs revealed no significant difference
(P > 0.05) (Table 2 and Fig. 4). As regards the amplitudes,
comparing the amplitudes of nI and pI of both modes of
oVEMPs revealed no statistically significant difference
(P > 0.05) (Table 1 and Figs. 4 and 5).
The inter-aural amplitude ratios (IARs) were calculated as
the following: 100 [(AR AL)/ (AR + AL)]. AR is the ampli-
tude on right side; AL is the amplitude on left side. The IARs
of P13 and N23 showed no significant difference between indi-
vidual and combined modes (P > 0.05). In case of oVEMP,
the IARs of nI and pI in both individual and combined modes
are (P > 0.05) (Table 2).
Pearson correlation was done to find any significant rela-
tion between VEMPs latencies and amplitudes in both modes.
In case of cVEMPs, there was a strong positive correlation be-
tween individual and combined cVEMPs. The same was no-
ticed in case of oVEMPs (Fig. 6).
6. Discussion
Since the first description of cVEMPs by Colebatch and Hal-
magi13 they have been used as a standard clinical test with doc-
umented utility in various vestibular and central nervous
system disorders.5,9 The primary recording site that is used
clinically is the SCM muscle and is thought to be mediated
through the ipsilateral descending sacculo-collic reflex path-
way.14 Despite its benefits, the procedure still has limitations
as regards eliciting VEMPs from the SCM muscle of patients
with poor muscle tone, poor range of motion in the neck
and the pediatric and geriatric populations.15
Ocular VEMPs are best recorded from extra ocular muscles
slightly below the eye contralateral to stimulation side.5,9
These potentials are myogenic in nature and arise from the ves-
tibulo-ocular reflex (VOR) and pass through the crossed
ascending VOR pathway.16
116 T.H. El-Mahallawi et al.

Figure 1 Example of VEMPs response in a subject from the study using different recording procedures.

Table 1 Comparison between mean and standard deviation of latency and amplitudes of P13 and N23 components of cVEMPs and
nI and pI components of oVEMPs in individual and combined modes.
cVEMPs oVEMPs
Individual Combined t-test p-value Individual Combined t-test p-value
Latency
P13 17.27 ± 2 17.88 ± 1.6 0.852 0.669 nI 11.58 ± 1.5 12.5 ± 1.2 0.741 0.320
N23 25.2 ± 1.8 25.47 ± 1.7 0.471 0.530 pI 14.3 ± 1.9 16.55 ± 1.8 0.741 0.253
Amplitude
P13 11.95 ± 9.18 12.19 ± 9.35 0.357 0.148 nI 0.88 ± 0.44 0.89 ± 0.25 0.963 0.841
N23 11.16 ± 7.26 11.19 ± 7.74 1.235 0.558 pI 0.85 ± 0.3 0.99 ± 0.7 0.741 0.253

Results of this study showed that cVEMPs could be re- modes of stimulation. This agreed with Chou et al.12 However,
corded in all healthy subjects in both individual and combined oVEMPs were recorded in 94% of subjects in both individual
Vestibular evoked myogenic potentials (VEMPs) with different recording procedures 117

Figure 2 Mean of P13 and N23 latencies in both individual and combined modes of recording.

Figure 3 Mean of P13 and N23 amplitudes in both individual and combined modes of recording.

Table 2 Comparison between IARs of P13 and N23 of cVEMPs and nI and pI of oVEMPs in individual and combined modes.
IARs (%) cVEMPs oVEMPs
Individual Combined Individual Combined
P13 23.11 ± 18.3 26.87 ± 20.9 24.63 ± 3.03 21.25 ± 3.36
t. test 2.325 1.302
p. value 0.07 0.963
N23 24.6 ± 18.7 27.2 ± 19.5 18.4 ± 2.7 21.1 ± 3.24
t. test 3.325 1.305
p. value 0.052 0.417

Figure 4 Mean of nI and pI latencies in both individual and combined modes of recording.
118 T.H. El-Mahallawi et al.

Figure 5 Mean of nI and pI amplitudes in both individual and combined modes of recording.

Figure 6 Results of Pearson correlation between single and combined mode of cVEMPs and oVEMPs.

and combined modes. This is not consistent with the same
authors who reported that oVEMPs could be recorded in all
healthy subjects in both modes of recordings. The small num-
ber of subjects with absent oVEMPs (three subjects only)
could be explained by inefficient muscular contraction or mus-
cle fatigue17 Both cVEMPs and oVEMPs showed no signifi-
cant difference between right and left ears as regards
latencies or amplitudes of their components in either individ-
ual or combined mode of recording. This agreed with Chou
et al.,12 indicating more symmetrical and consistent response
across the ipsilateral and contralateral vestibular ascending
and descending pathways.
As regards cVEMPs, P13 latencies were 17.27 ± 1.99 ms and
17.88 ± 1.58 ms in both individual and combined modes
respectively. N23 latencies were 25.20 ± 1.8 ms and 25.47 ±
1.69 ms in both individual and combined modes respectively.
Comparing the latencies of P13 and N23 of both modes of
cVEMPs revealed no significant difference (P > 0.05). This
agreed with Todd et al.18 and Khalil and Elkabariti.19 However,
our results disagreed with Wang and Young20 who reported
14.43 ± 1.97 ms as P13 latency and 21.82 ± 1.84 ms as N23 la-
tency. Moreover, Wang and Young21 reported 14.08 ± 1.27 ms
as P13 latency and 20.66 ± 1.52 ms as N23 latency using the
ideal stimulation parameters for the VEMPs recording. This
could be due to different recording procedures as those authors
used binaural simultaneous recording procedure.
As regards cVEMPs amplitudes, P13 amplitudes were
11.95 ± 9.18 lv (individual) and 12.19 ± 9.35 lv (combined).
Vestibular evoked myogenic potentials (VEMPs) with different recording procedures
N23 amplitudes were 11.16 ± 7.26 lv (individual) and
11.19 ± 7.74 lv (combined). Comparing both amplitudes in
both modes of cVEMPs recording showed no significant differ-
ence. The IARs of P13 were 23.11 ± 18.3% (individual) and
26.87 ± 20.9% (combined) with no significant difference. As
regards N23, IARs were 24.6 ± 18.7% (individual) and
27.2 ± 19.5% (combined) with no significant difference also.
This agreed with Alpini et al.,22 and Chou et al.12 As regards
the inter-aural amplitude ratios (IARs), comparing the IARs
of P13 and N23 of both modes of cVEMPs recordings revealed
no significant difference.
On recording oVEMPs, nI latencies were 11.58 ± 1.51 ms
(individual) and 12.5 ± 1.2 ms (combined). While, pI latencies
were 14.3 ± 1.9 ms (individual) and 16.55 ± 1.82 (combined).
Comparing both latencies in both modes of oVEMPs record-
ings showed no significant difference. As regards the ampli-
tudes, nI amplitudes were 0.88 ± 0.44 lv (individual) and
0.89 ± 0.25 lv (combined). pI amplitudes were 0.85 ± 0.3 lv
(individual) and 0.99 ± 0.7 lv (combined). Comparing both
amplitudes in both modes of oVEMPs recordings revealed no
significant difference. These results agreed with Rosengren,11
who reported 2.7 ± 2.7 lv as a mean nI amplitude and
2.3 ± 1.3 lv as mean pI amplitude. The IARs of nI were
24.63 ± 3.03% and 21.25 ± 3.36% in both individual and
combined modes respectively with no significant difference. In
case of pI, the IARs were 18.4 ± 2.7% and 21.1 ± 3.24% in
both individual and combined modes respectively with no sta-
tistically significant difference also. Results of IARs agreed with
Isaradisaikul et al.,23,24 who reported similar values for IARs.
The strong positive correlation between individual and
combined modes of cVEMPs and oVEMPs recordings in terms
of latency and amplitude indicated that the combined proce-
dure can substitute individual one.
Both oVEMPs and cVEMPs were elicited efficiently and
independently via air-conducted sound stimulation during
the same test session. This may be because oVEMPs have
much shorter latencies than cVEMPs, indicating that different
pathways lead to various phases in nerve impulse transmission.
In other words, the oVEMPs run via an oligosynaptic pathway
between the saccule and extra-ocular motor neurons. While,
cVEMPs run via a trisynaptic pathway from the saccule to
the neck muscles12. Together, cVEMPs and oVEMPs can be
used for assessing the ascending and descending vestibular
pathways in the brainstem.25,26
Park et al.,6 argue that the cVEMPs are more reliable and
robust measures than oVEMPs testing with some limitations
in patients with poor muscle tone, poor range of motion in
the neck and the pediatric or geriatric population19 oVEMPs
test is an easy and very rapid test that could be applied to geri-
atric and young children. Rosengren et al.,9 suggested that the
recording of extra-ocular potentials could extend the range of
central and peripheral vestibular and ocular pathways that can
be assessed electrophysiologically. The authors also suggested
using larger amplification during the acquisition of the re-
sponse given that the oVEMP waveform is considerably smal-
ler than the cVEMP response. Future studies should utilize this
suggestion for better visualization of the waveform.
In conclusion, this study showed that oVEMPs recording
can be done through a simple and non invasive procedure that
allows further investigation of central vestibular pathways,
specifically sacculo–ocular reflexes. Simultaneous recording
of both oVEMPs and cVEMPs can be done with a high degree
119
of accuracy and without affecting results of each other. This
would provide useful information about the vestibular path-
way: the ipsilateral descending vestibular pathway (through
cVEMPs) and the contralateral ascending pathway (through
oVEMPs) in a non-invasive, rapid and simple procedure. So,
the combined procedure is recommended to be used clinically
instead of the individual procedure in all patients with vestib-
ular pathway affection since it provides more information
about the other area along the vestibular pathway without
prolonging the test session. It is also recommended to study
combined VEMPs using bone conduction to standardize an-
other new combined recording procedure and extensively
study the vestibular system.
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