Acta Oto-Laryngologica.

2014; 134: 34–40

ORIGINAL ARTICLE

Vestibular evoked myogenic potential according to middle ear condition

in chronic otitis media with tympanic membrane perforation

JUN SEOK LEE, SUN KYU LEE, IL HO SHIN, SEUNG GEUN YEO, MOON SUH PARK &
JAE YONG BYUN

Department of Otorhinolaryngology-Head and Neck Surgery, School of Medicine, Kyung Hee University, Seoul, Korea

Abstract
Conclusion: Vestibular evoked myogenic potential (VEMP) function results can vary between individuals with different middle
ear conditions. Therefore, by analyzing VEMP results after paper patching, we can predict the condition of the middle ear in
chronic otitis media (COM) patients. Objectives: VEMP responses decrease with impairment of sound transmission, such as in
conductive hearing loss (CHL). COM with tympanic membrane (TM) perforation is a common disorder that causes various
degrees of CHL. The aim of this study was to evaluate and clarify the VEMP responses in patients with COM with different
middle ear pathology. Methods: This study included 50 patients with unilateral COM with TM perforation. Initial pure-tone
audiometry (PTA) and VEMP responses were recorded. After paper patching, PTA and VEMP were re-performed. Each
VEMP response was compared with those of the healthy controls. Moreover, VEMP responses between pre- and post-paper
patching were compared. Results: There was a positive correlation between normalizing of VEMP parameters, such as p13 and
VEMP asymmetry ratio (VAR), and reduction of air–bone gap in patients with COM after paper patching. The VEMP
response in patients with COM with intact ossicle and clean mucosa was more normalized compared with those in patients with
COM with different middle ear conditions.

Keywords: Conductive hearing loss, paper patch, air–bone gap, VEMP asymmetry ratio

Introduction CHL or mixed hearing loss, depending on different

Vestibular evoked myogenic potential (VEMP) is the
reflex myogenic potential of neck muscles that is
elicited by stimulating the vestibular system of the
ear with a click or tone-burst sound. VEMPs have
recently become a clinical tool for evaluating the
sacculo-collic reflex, and they have been broadly
studied in patients with cochleo-vestibular disorders
[1]. Because the VEMP is evoked by loud sound
stimulation, impairment of sound transmission
through the middle ear may affect VEMP results.
VEMP responses are decreased in cases of
impairment of sound transmission, such as conduc-
tive hearing loss (CHL). Chronic otitis media (COM)
with tympanic membrane (TM) perforation is a com-
mon middle ear disease that causes various degrees of
middle ear pathologic conditions. VEMP responses
are decreased although VEMP responses are elicited
in patients with COM [2]. However, the VEMP
responses of patients with COM according to differ-
ent middle ear conditions such as ossicular status or
the middle ear mucosal status remains unclear [3].
We hypothesize that VEMP responses may differ
according to different middle ear conditions that can
influence the air–bone gap (ABG) in CHL in patients
with COM with TM perforation. This ABG can be
reduced promptly by the application of a paper patch
if not all before surgery. The aim of this study was to
detect the effects of middle ear conditions on VEMP
responses and to clarify the changes in VEMP para-
meters after paper patching in each middle ear
condition.

Correspondence: Jae Yong Byun MD PhD, Department of Otorhinolaryngology-Head and Neck Surgery, Kyung Hee University Hospital at Gangdong,
#149 Sangil-dong, Gangdong-gu, Seoul 134-090, Korea. Tel: +82 2 440 6182. Fax: +82 2 440 7336. E-mail: otorhino512@naver.com

(Received 18 May 2013; accepted 7 August 2013)

ISSN 0001-6489 print/ISSN 1651-2251 online
2014 Informa Healthcare
DOI: 10.3109/00016489.2013.836756
 VEMPs according to middle ear conditions in COM
Material and methods
Fifty patients (28 males, 22 females) with unilateral
TM perforation due to COM were included in this
study. Eardrum perforation was diagnosed with an
otoscope and confirmed with tympanometry. We
excluded patients with a history of vertigo, neurolog-
ical disorders, external auditory canal lesions, any
inner ear anomaly, and cholesteatoma.
The ages of participants ranged from 21 to 71 years;
the mean age was 48.3 years. The right side was
affected in 18 patients, while 32 were affected on
the left side. The air conduction hearing threshold
levels were determined as the average of pure-tone
thresholds of 500 Hz, 1 kHz, and 2 kHz. All patients
had CHL (mean ABG more than 15 dB in 500, 1000,
and 2000 Hz) on pure-tone audiometry (PTA).
After confirmation of the inclusion criteria, PTA
and VEMP tests were performed. Following the PTA
and VEMP tests, we applied a paper patch on the
perforation side. Repeat PTA and VEMP tests were
performed after 1 h to allow for drying.
For the recording of VEMP, the patients were in a
sitting position. The sound stimuli (500 Hz, 90 dB
nHL short tone burst) were conducted to the ears
monoaurally with an insertion-type earphone. The
electromyographic signals were amplified and col-
lected with a bandpass filter using a digital system
(model Navigator Pro Loader Ver. 5.1, Bio-Logic
System Corp., Mundelein, IL, USA). The analysis
time was 53.3 ms. The responses to 64 stimuli were
averaged for 1 trial, and 2 trials were acquired for
1 complete test. The initial positive/negative polarity
of the waveform with peaks identified as p13 and
n23 on the basis of their latency was used to identify
the presence or absence of VEMPs. Then, the laten-
cies of p13 and n23 and the amplitudes of
p13-n23 were measured. The VEMP asymmetry ratio
(VAR) was calculated as (Au–Aa)/(Aa+Au), where
Au is the amplitude of p13-n23 on the unaffected side
and Aa is the p13-n23 amplitude on the affected side.
The latencies of p13 and n23 of the two trials were
averaged to represent the latencies of each test, and
the maximum of the p13-n23 amplitudes of the two
trials was considered the amplitude of the test. The
p13 latency of the healthy control participants
(26 males and 19 females aged 43.2 ± 15.4 years)
at our laboratory was 18.4 ± 2.9 ms (mean ± SD). The
latency of n23 was 27.44 ± 3.92 ms and the VAR of
the healthy controls was 19.30 ± 4.56%. During the
surgery (tympanomastoidectomy or tympanoplasty),
we verified TM perforation size, ossicular mobility,
and middle ear mucosa status.
The differences in VEMP results after patch appli-
cation according to middle ear condition in the pre-
35
patch and post-patch groups were tested with
Student’s t test or the Mann–Whitney U test. Statis-
tical significance was assumed at p < 0.05. The
changes in VAR and latencies after paper patching
according to changes in ABG were tested with Pear-
son correlation. The Statistical Package for the Social
Sciences (SPSS) Windows Release 10.0.1 (SPSS Inc.,
Chicago, IL, US) was used for statistical analyses.
We explained the process of PTA and VEMP and
obtained informed consent from patients. The Insti-
tutional Review Boards (IFC/IRB) of the Kyung Hee
University Hospital at Gangdong (Seoul, Korea)
approved the protocol of this study.
Results
Fifty patients with COM exhibited CHL with a mean
hearing threshold of 47.7 ± 23.7 dB and a mean ABG
of 26.8 ± 11.3 dB. The hearing threshold levels and
ABGs of the participants with COM improved sig-
nificantly after paper patching (Table I, p < 0.05).
Before patching, the VEMP response rate on ipsilat-
eral stimulation was 64% (32/50), and it increased to
86% (43/50) after the paper patch was applied
(p < 0.05, Chi-squared test), defining absent VEMP
as less than 15 mV of p13-n23 interamplitude. Of the
seven participants with no VEMP after paper patch-
ing, all had moderate to severe hearing loss. Figure 1
shows the VEMP responses of one study participant
with right-sided COM. After paper patching, a 10 dB
improvement of average hearing threshold levels was
noted in the frequency range of 250–8000 Hz. The
p13 and n23 latencies were delayed and interampli-
tude was decreased in the right-sided (affected side)
stimulations before paper patching (Figure 1B) How-
ever, the VEMP responses on the affected side
showed a shortening of latency and an increase of
interamplitude after paper patching (Figure 1D). Fol-
lowing the paper patch procedure, p13 latency and
VAR were significantly decreased in the COM group
(Table I).
We divided COM patients according to the status
of the ossicular chain, middle ear mucosa status, and
the size of eardrum perforation, which can affect
sound transmission. Then we analyzed the VEMP
parameters of each condition after paper patch
application.
Effect of TM perforation size
We used microscopic examination of the entire TM to
determine the size of the perforations. We defined the
small-to-moderate-sized group as those patients hav-
ing a perforation size of less than 50% relative to the
entire TM, and patients with greater than 50%
36 J. S. Lee et al.

Table I. General characteristics and results of vestibular evoked myogenic potential testing and pure-tone audiometry.
Characteristic Normal controls COM patients COM patients p Value between
before patching after patching pre- and post-patch

No. of subjects 40 50
Age 43.2 ± 15.4 48.3 ± 14.6
Male:female 26:19 24:26
AC threshold average (dB) 6.1 ± 5.5 47.7 ± 23.7* 42.1 ± 24.2* 0.000†
AC threshold at 500 Hz (dB) 12 ± 14.2 50.8 ± 22.5* 44.2 ± 23.8* 0.000†
BC threshold average (dB) 2.3 ± 5.8 20.8 ± 18.1* 20.9 ± 17.4* 0.043†
BC threshold at 500 Hz (dB) 4.0 ± 9.7 16.0 ± 13.9* 17.0 ± 14.4* 0.286
ABG average (dB) 3.8 ± 2.3 26.8 ± 11.3* 21.2 ± 10.7* 0.000†
ABG at 500 Hz (dB) 8.0 ± 9.2 34.8 ± 16.8* 27.2 ± 15.4* 0.000†
VEMP
p13 latency (ms) 18.4 ± 2.9 21.9 ± 5.6* 19.6 ± 5.2 0.030†
n23 latency (ms) 27.44 ± 3.2 27.7 ± 5.8 27.4 ± 5.6 0.302
VAR (%) 19.30 ± 4.56 36.5 ± 17.8* 30.8 ± 17.2* 0.042†
ABG, air–bone gap; AC, air conduction; BC, bone conduction; COM, chronic otitis media; VAR, VEMP asymmetric ratio; VEMP, vestibular
evoked myogenic potential.
*Difference from normative data of normal controls with p < 0.05; †p < 0.05.

perforation were placed into the large-sized group.
The small-to-moderate-sized perforation group
included 22 patients (16 tympanoplasties and 6 tym-
panomastoidectomies) and the large-sized group
included 28 patients (7 tympanoplasties and 21 tym-
panomastoidectomies). No VEMP parameters showed
any significant change after paper patching in the small-
to-moderate-sized perforation group. However, in the
patients with large-sized perforations, the p13 latency
significantly decreased (Table II).
(10 tympanomastoidectomies). In the normal mucosa
group, the interamplitude was 24.1 ± 5.9 mV, which
significantly increased to 31.6 ± 6.7 mV after the paper
patching procedure; therefore, VAR significantly
decreased from the values of 28.8 ± 4.6% to 19.1 ±
5.9% after paper patching (p < 0.05). In the moderate
granulation or severe granulation group, no VEMP
parameters changed significantly (Table III).

Effect of the ossicular chain status

Effect of middle ear mucosa status
We divided our participants into three additional
groups according to their intraoperative middle ear
mucosa status. We were concerned about the middle
ear mucosal status in the middle ear cavity after
tympanomeatal flap elevation, and therefore placed
patients with nearly absent normal middle ear mucosa
into the severe pathologic mucosal group. If patients
had mucosa with edematous changes in some part of
the tympanic cavity (less than half of the total area of
cavity), those patients were divided into the moderate
pathologic changes mucosal group; patients with no
granulation tissue were classified as being in the clean
mucosa group. The normal mucosa group comprised
20 patients (16 tympanoplasties and 4 tympanomas-
toidectomies), the moderate pathologic changes
mucosal group comprised 20 patients (7 tympanoplas-
ties and 13 tympanomastoidectomies), and the
severe granulation group comprised 10 patients
During ear surgery, we checked ossicular chain status
by assessing the mobility of the malleoincudal, incu-
dostapedial (MI, IS) joint with slight tapping pressure
on the malleus handle. We defined intact MI, IS joint
mobility as an intact ossicular chain, and the absence
or destruction of the ossicle was defined as ossicular
discontinuity. The intact ossicular chain group com-
prised 22 patients (17 tympanoplasties and 5 tympa-
nomastoidectomies) and the ossicular discontinuity
group comprised 28 patients (6 tympanoplasties and
22 tympanomastoidectomies). In the intact ossicular
chain group, the p13 latency was initially 21.3 ±
6.1 ms, and it significantly decreased to 17.3 ±
5.6 ms after the paper patch procedure. The
n23 latency and VAR represented a nonsignificant
difference from the values obtained after paper patch-
ing (p > 0.05). However, in the ossicle discontinuity
group, there was no significant change in any VEMP
parameter after paper patching (Table IV).
 VEMPs according to middle ear conditions in COM 37

Figure 1. The pure-tone audiograms and vestibular evoked myogenic potentials (VEMPs) of a participant with right-sided tympanic
membrane perforation with, chronic otitis media (COM) before paper patching (A, B) and after paper patching (C, D). O, X, right, left,
air conduction level; D, right air conduction level with masking; [, right bone conduction level.

Discussion method in cases of sudden sensorineural hearing

Many factors can affect the VEMP, including age,
stimuli, laterality, middle ear status, and muscle ten-
sion [4]. Halmagyi et al. reported that VEMP
responses are typically absent in cases of CHL with
an ABG of greater than 20 dB [5]. Before paper
patching, the mean ABG of 50 affected ears of our
patients with COM was 24.6 ± 10.9 dB. As the paper
patch significantly attenuated the ABG, a VEMP
response was elicited in up to 86%, which was
increased from 64%, assuming less than 15 mV of
p13-n23 interlatency as absence of VEMP. The
VEMP response rate obtained by the tone burst
loss was 100%, implying that an absence of VEMP
by the tone burst method was caused by CHL, but not
by sensorineural hearing loss [6]. A typical sound-
induced VEMP response requires good energy trans-
fer to the inner ear, meaning that an intact middle ear
is necessary. Many alternative methods of overcoming
CHL, such as the tapping method or the use of bone-
conduction stimuli, have been reported [2,7–10].
Wang and Lee collected VEMP responses in patients
with middle ear effusion (MEE) and compared the
responses with those of both healthy controls and the
same participants after tympanic aspiration to clarify
the effects of MEE on VEMP responses [3]. They
38 J. S. Lee et al.

Table II. Difference in pure-tone audiometry and vestibular evoked myogenic potential testing by paper patching according to the size of the
tympanic membrane perforation.
Perforation size Characteristic COM patients COM patients p Value between
before patching after patching pre- and post-patch

< 50% (n = 22) ABG average (dB) 24.6 ± 11.5 21.9 ± 11.4 0.007*
ABG at 500 Hz (dB) 27.7 ± 15.8 25.0 ± 15.1 0.158
VEMP
p13 latency (ms) 21.2 ± 4.5 19.7 ± 5.9 0.641
n23 latency (ms) 27.8 ± 3.7 27.1 ± 6.6 0.351
VAR (%) 35.2 ± 25.5 31.5 ± 17.9 0.079
‡ 50% (n = 28) ABG average (dB) 28.5 ± 11.0 20.6 ± 10.3 0.000*
ABG at 500 Hz (dB) 40.4 ± 15.6 28.9 ± 15.7 0.000*
VEMP
p13 latency (ms) 22.9 ± 5.5 19.5 ± 4.6 0.071
n23 latency (ms) 27.6 ± 6.4 27.7 ± 4.8 0.371
VAR (%) 37.2 ± 18.9 31.7 ± 16.7 0.063
ABG, air–bone gap; AC, air conduction; BC, bone conduction; COM, chronic otitis media; VAR, VEMP asymmetric ratio; VEMP, vestibular
evoked myogenic potential.
*p < 0.05.

reported that the VEMP asymmetry ratio was signif-
icantly decreased, and the latencies of p13 and
n23 returned to the range of control participants
immediately after tympanic aspiration. We suspect
that the paper patch helps sound energy transfer to
the inner ear. In the present study, the latency of
p13 and n23 had a tendency of mild delay, which was
not seen in other studies. We thought that the reason
for this discrepancy was probably due to differences in
sound stimuli. We used a 90 dB, 500 Hz short tone
burst sound instead of the 95 dB sound used in other
studies. Commonly, VEMP stimulation is by a
500 Hz, 90 dB nHL, or 95 dB nHL short tone burst.
Our laboratory data were relatively stable and consis-
tent when the stimulus was 90 dB nHL. The
p13 latency and p13-n23 interamplitude of the
COM group were significantly different from those
of the control group. After paper patching, the
p13 latency delay was significantly decreased and
the p13-n23 interamplitude significantly increased.
The ABG also decreased after paper patching. Based
on the significant shortening of p13 latency after paper
patching, a decrease in energy transfer to the middle
ear seemed to be the major cause of the delay in
VEMP latencies in patients with COM. However,
the n23 latency showed no difference between con-
trols and patients with COM, and the reason for this
was unclear. Based on these results, we can partially
predict the presence or absence of the VEMP
response on an audiogram according to the ABG.
We subdivided the patient groups according to
variable conditions, such as ossicle chain status, mid-
dle ear mucosa condition, and the size of the eardrum
perforation intraoperatively, which could affect sound
energy transmission. In cases with an intact ossicular
chain, the p13 latency of 21.3 ± 6.1 ms was signifi-
cantly decreased to 17.3 ± 5.6 ms after paper patch-
ing, whereas no significant change was observed in
ossicular chain discontinuity. According to the con-
dition of the middle ear mucosa, the p13 latency and
the VAR showed significant changes only in patients
with clean mucosa by paper patching. There were no
significant changes in p13, n23 latency or the VAR in
patients with any degree of middle ear granulation.
There were also no significant changes of latency or
VAR by paper patching regardless of the TM perfo-
ration size. Therefore, we can assume that the influ-
ence of the ossicle and middle ear mucosa status on
sound transmission might be important for eliciting
VEMP response. Because any degree of ossicular
chain discontinuity in patients with COM may
directly interfere with air conduction, less acoustic
energy is transmitted into the inner ear when using air
conduction acoustic stimulation. The p13 latency was
significantly shortened in the intact ossicular chain
group after paper patching; based upon this result, we
assumed that it was mainly affected by the velocity of
acoustic energy transmission rather than the ampli-
tude. There were no changes in VEMP parameters in
patients with ossicular discontinuity after paper patch-
ing. In COM patients with middle ear granulation, no
parameters changed. This finding indicates that
 VEMPs according to middle ear conditions in COM 39

Table III. Difference in pure tone audiometry and vestibular evoked myogenic potential by patching according to the middle ear mucosal
status.
Middle ear mucosa status Characteristic COM patients COM patients p Value between
before patching after patching pre- and post-patch

Normal (n = 20) ABG average (dB) 26.1 ± 10.8 17.0 ± 10.2 0.001*
ABG at 500 Hz (dB) 31.0 ± 14.5 27.5 ± 16.7 0.045*
VEMP
p13 latency (ms) 21.3 ± 3.5 18.7 ± 7.1 0.043*
n23 latency (ms) 26.7 ± 6.3 27.8 ± 6.6 0.948
VAR (%) 28.8 ± 4.6 19.1 ± 5.9 0.012*
Moderate pathologic ABG average (dB) 24.1 ± 11.4 21.8 ± 11.0 0.012*
state (n = 20) ABG at 500 Hz (dB) 31.5 ± 16.7 22.5 ± 14.4 0.001*
VEMP
p13 latency (ms) 21.9 ± 5.3 19.9 ± 3.2 0.307
n23 latency (ms) 27.9 ± 6.4 25.5 ± 5.1 0.479
VAR (%) 35.8 ± 38.3 32.9 ± 22.5 0.061
Severe pathologic AB gap average (dB) 33.3 ± 10.4 28.3 ± 7.5 0.111
state (n = 10)
ABG at 500 Hz (dB) 49.0 ± 14.7 36.0 ± 11.3 0.111
VEMP
p13 latency (ms) 23.3 ± 4.1 22.5 ± 3.0 0.101
n23 latency (ms) 29.2 ± 4.1 28.4 ± 4.1 0.331
VAR (%) 45.7 ± 28.8 45.1 ± 34.3 0.274
ABG, air–bone gap; AC, air conduction; BC, bone conduction; COM, chronic otitis media; VAR, VEMP asymmetric ratio; VEMP, vestibular
evoked myogenic potential.
*p < 0.05.

Table IV. Difference in pure tone audiometry and vestibular evoked myogenic potential by patching according to the state of the ossicular
chain.
Ossicle state Characteristic COM patients COM patients p Value between
before patching after patching pre and post-patch

Intact ossicular ABG average (dB) 24.6 ± 12.8 18.1 ± 14.5 0.001†
chain (n = 22)
ABG at 500 Hz (dB) 27.1 ± 6.4 18.3 ± 8.1 0.001†
VEMP
p13 latency (ms) 21.3 ± 6.1 17.3 ± 5.6 0.028†
n23 latency (ms) 27.7 ± 6.4 25.4 ± 6.2 0.157
VAR (%) 35.4 ± 27.8 29.3 ± 24.8* 0.068
Ossicular ABG average (dB) 28.3 ± 22.1 24.1 ± 20.02 0.102
discontinuity (n = 28) ABG at 500 Hz (dB) 36.9 ± 21.8 34.1 ± 17.9 0.381
VEMP
p13 latency (ms) 22.2 ± 3.6 21.6 ± 3.3 0.116
n23 latency (ms) 29.1 ± 2.8 28.1 ± 4.8 0.307
VAR (%) 36.9 ± 22.1 33.9 ± 20.1 0.179
ABG, air–bone gap; AC, air conduction; BC, bone conduction; COM, chronic otitis media; VAR, VEMP asymmetric ratio; VEMP, vestibular
evoked myogenic potential.
*Difference from normative data of normal controls with p < 0.05; †p < 0.05.
40 J. S. Lee et al.
granulation tissue may absorb some sound energy,
and in the presence of granulation tissue, the para-
meters of VEMP were not changed following paper
patching. Acoustic energy impinged on a perforated
TM, and the reduced transforming action attenuated
the stimulated sound, leading to absent VEMPs. The
rates of p13 and n23 latency and VAR of COM
patients were in normal ranges (average ± 2 SD):
16%, 24%, and 8%, respectively. After paper patch-
ing, however, these rates increased to 27%, 43%, and
16% when the ipsilateral COM side was compared
with same side in the control group.
These findings indicate that paper patching rein-
forced some portion of the attenuated acoustic
energy. Therefore, we should be aware that the effects
of middle ear conditions, such as the status of the
ossicular chain and the middle ear mucosa, may
influence VEMP response in patients with COM
with TM perforation who need VEMP tests.
Considering the middle ear conditions and audio-
logic findings in the present study, we can suggest that
more accurate VEMP results can be obtained for
patients with COM through the application of a paper
patch. Conversely, we can suggest that VEMP scores
reflect middle ear conditions, and thus the VEMP
itself could be a diagnostic tool that can allow for
preoperative monitoring of the condition of the mid-
dle ear.
Conclusion
VEMP responses could be affected by a patient’s
middle ear status. In COM with TM perforation,
the VEMP latency was significantly delayed and the
asymmetry ratio was significantly increased. In pati-
ents with TM perforation who need VEMP testing,
the VEMP response may be influenced by middle ear
conditions, such as perforation and the status of the
ossicular chain. If we consider middle ear conditions
and audiologic findings, we can obtain better VEMP
results and proper diagnosis in dizzy patients with
TM perforation through paper patching. In addition,
we suggest that VEMP reflects middle ear conditions,
and thus VEMP could be an informative tool to
identify middle ear conditions preoperatively.
Acknowledgment
This research was supported by the Kyung Hee
University Research Fund in 2010 (KHU-20100740).
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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