1. Averroes Prize
Dr M. Abou Elew (Egypt)

2. 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

3. 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

4. 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

5. 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

6. 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

7. Results
MGSD- Athenes 29 April 2017

8. 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

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

10. 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

11. 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

12. 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

13. 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

14. 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

15. Balance Exercises
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16. Gait Exercises:
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17. Gait Exercises
MGSD- Athenes 29 April 2017

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