Averroes Prize Dr M. Abou Elew (Egypt)

ASSESMENT OF VESTIBULAR FUNCTIONS IN PATIENTS WITH DIABETES MELLITUS Dr. Maha Abou-Elew Prof. of Audio-Vestibular Medicine, ORL Department- Cairo University, EGYPT MGSD- Athenes 29 April 2017

Introduction Diabetes mellitus and its complications are rapidly becoming the world most significant cause of morbidity and mortality. Most diabetics complain of imbalance and /or dizziness. Although diabetic sensory neuropathy and retinopathy are well-researched topics, relatively few studies focused on the effects of DM on the vestibular system and balance MGSD- Athenes 29 April 2017

Objectives The aim of this study is: To detect the changes of vestibular function; through the vestibulospinal reflex (VSR); in diabetic patients and To correlate it with the severity of diabetes. MGSD- Athenes 29 April 2017

Methodology Subjects: The study included 40 adult patients with DM type II, compared to 40 healthy age and sex matched control subjects. Exclusion criteria: hypertension, vascular insufficiency, history of major head trauma, neurological disease and musculoskeletal disorders that contribute to postural instability, previous otological disease, or any history of vestibular dysfunction before the onset of diabetes. MGSD- Athenes 29 April 2017

Methodology (Cont.) Methods: All subjects included in the study were submitted to: Neurological examination, Michigan neuropathy score (MNSI) for peripheral neuropathy, Cervical vestibular evoked myogenic potential (c VEMP), Laboratory investigations including FPG, 2HPP and Hb A1C. The grade of peripheral neuropathy, level of Hb A1c and duration of DM were compared to vestibular test results. MGSD- Athenes 29 April 2017

Results MGSD- Athenes 29 April 2017

Table 1: Comparison between the study group and the control group regarding threshold and waves latencies of cVEMP in both ears cVEMP Study group Mean (± SD) Control group P value Right ear Threshold (dBHL) 93 (±5.45) 86.54 (±4) <0.001 P 13 latency (ms) 16.43 (±1.57) 13.21 (±0.77) N 23 latency (ms) 24.26 (±1.80) 22.9 (±1.06) 0.002 Left ear 92.65 (±5.07) 86.62 (±3.34) 15.95 (±1.74) 13.48 (±0.5) 23.93(±1.65) 22.97 (±0.99) 0.006 Diabetic patients had significantly higher threshold and wave latencies (delayed P13 and N23 waves) in both ears than the control group. NB: The study group had 35 responses in from Rt ear and 32 from Lt ear. The control group had 39 responses from Rt ear and 37 from left ear. MGSD- Athenes 29 April 2017

Figure 1: cVEMP response of both ears recorded from a patient in the study MGSD- Athenes 29 April 2017

Non-neuropathic group Table 2: Comparison between cVEMP results in the right ear according to: grade of peripheral neuropathy, glycemic control by HbA1c, and duration of diabetes. cVEMP Mean (± SD) Neuropathic group (n=19/24) Non-neuropathic group (n=16/16) P value Threshold (dBHL) 96.31(±4.66) 89.06(±3.27) <0.001 P 13 latency (ms) 17.49(±0.92) 15.17(±1.22) N 23 latency (ms) 25.32(±1.05) 23(±1.69)   Poor control group (n=22/27) Good control group (n=13/13) 95(±5.11) 89.61(±4.31) 0.003 17.34(±1) 14.41(±1.5) 24.87(±1.31) 23.22(±2.07) 0.019 Duration >5 years (n=20/24) Duration <5 years (n=15/16) 96(±4.47) 89 (±3.87) 17.3(±1.01) 15.26(±1.43) 24.92(±1.58) 23.38(±1.72) 0.01 In diabetic patients, those with peripheral neuropathy, poorer glycemic control and disease duration > 5 years had significant higher cVEMP alterations. MGSD- Athenes 29 April 2017

Table 3: Correlation between cVEMP results and DM duration, level of HbA1c and MNSI score Right ear Threshold R* 0.588 0.668 0.817 P value 0.000 P13 latency 0.557 0.805 0.841 0.001 N23 latency 0.466 0.637 0.653 0.005 Left ear 0.689 0.563 0.728 0.464 0.677 0.760 0.008 0.499 0.560 0.004 Severity of neuropathy grade had the strongest correlation with cVEMP results followed by level of HbA1c and finally the disease duration. *R is calculated by Pearson correlation coefficient. -Correlation is weak when R< 0.5, moderate when R from 0.5 to 0.7 and strong when R> 0.7 -P is significant when <0.05 MGSD- Athenes 29 April 2017

Conclusion Vestibular dysfunction might occur despite the absence of vestibular symptoms in diabetic patients. This could be due to absence of asymmetry and the gradual affection. The predominant mechanisms are: - microangiopathy of the inner ear, - neuropathy of the 8th cranial nerve - outer hair cell dysfunction and - disruption of the endolymphatic potential. MGSD- Athenes 29 April 2017

Conclusion (Cont.) Diabetic patients have a subclinical vestibular deficit that may appear with progression of diabetic complications. The alternation in vestibular function is more correlated to the severity of neuropathy than the glycemic control and disease duration. MGSD- Athenes 29 April 2017

Recommendations Baseline vestibular assessment with serial follow up is recommended in diabetic patients even in absence of dizziness symptoms. Strict management of peripheral neuropathy and proper glycemic control are important for diabetic patients to avoid impairment of balance problems associated with vestibular dysfunction. MGSD- Athenes 29 April 2017

Balance Exercises MGSD- Athenes 29 April 2017

Gait Exercises: MGSD- Athenes 29 April 2017

Gait Exercises MGSD- Athenes 29 April 2017

Thank you mahabouelew@kasralainy.edu.eg ORCID: 0000-0003-3895-6430 MGSD- Athenes 29 April 2017