As visually stimulating examination, outline of gaze-evoked nystagmus, rebound nystagmus, saccade, smooth pursuit and optokinetic examination were provided We provide an outline of the responses in optokinetic nystagmus testing, including gaze-evoked nystagmus, rebound nystagmus, saccade, and smooth pursuit. The history and underlying physiology, the comprehensive testing procedure and representative findings are described.

　In Japan,“gaze-nystagmus” refers to gaze-evoked nystagmus and spontaneous nystagmus under eye fixation; the former is caused mainly by damage of the paramedian pontine reticular formation, and the latter by imbalance of peripheral vestibular function. Rebound nystagmus includes directional alternation of gaze-evoked nystagmus during lateral fixation, and also alternation immediately after change of the gaze direction from lateral to forward. Congenital nystagmus is also characterized by bi-directional gaze-evoked nystagmus, although sometimes it takes the form of pendular nystagmus. Opsoclonus and ocular flutter manifest as bi-directional saccade movements without inter-saccadic intervals, caused by cerebellar disinhibition of neuronal bursts. On the other hand, square-wave jerks are characterized by saccadic intrusions with inter-saccadic intervals of about 200-400ms.

　Saccadic ocular movements are controlled by neuronal bursts, which are integrated at the neural integrator, to maintain lateral gaze. Omnipause neurons continuously inhibit this neuron bursting, and loss of this inhibition causes saccade movements. This system is controlled through the superior colliculus. Dysmetria of saccade movements is caused by cerebellar deficit.

　Smooth tracking movements are used to fix the images of moving objects on the fovea. Velocity information for such tracking is delivered through the medial vestibular nucleus and nucleus prepositus hypoglossi, which receive neural projections from the cerebellar flocculus. Cerebellar dysfunction causes saccadic pursuit, which is considered as being attributable to decreased gain of pursuit and consequent catch-up saccade.

　Accelerating head movements trigger the vestibulo-ocular reflex, which fixate one's visual line on an object. However, uniform head motion cannot trigger the vestibulo-ocular reflex, and requires another system; in this case, it is achieved by pursuit and optokinetic eye movements. The optokinetic reflex is disturbed by cerebellar deficit, which causes decreased gain of the optokinetic reflex and consequent catch-up saccade. Congenital nystagmus may also manifest as saccadic optokinetic nystagmus, which exhibits directional “inversion.”

　Vestibular migraine is a new diagnostic entity proposed recently by the International Headache Society. The diagnosis is based on the clinical course, including the evident relationship between the dizziness attacks and headache. The Headache Diary is already in use for the diagnosis of migraine. However, no clinical diary has been developed in which both headache and dizziness can be recorded at the same time. We have developed the “Dizziness and Headache Diary,” in which both symptoms can be recorded. Herein, we report the case of a 51-year-old female patient in whom vestibular migraine was successfully diagnosed based on her records in the diary. The diary records confirmed the close association between her dizziness episodes and headache, which is one of the mandatory criteria for the diagnosis of vestibular migraine. Thus, the “Dizziness and Headache Diary” is useful for the diagnosis of vestibular migraine.

　Recent advances in high-resolution MRI have enabled clear visualization of each nerve (cochlear nerve, vestibular nerve and facial nerve) in the internal auditory canal (IAC). Cochlear nerve deficiency (CND) is one of the known causes of bilateral or unilateral hearing loss in children. Although a narrow IAC was thought to be the cause of CND before the emergence of high-resolution MRI, recent studies have reported cases of CND associated with a normal IAC size as assessed by MRI; thus, CND is not able to diagnose by only existing a narrow IAC. There have been a few reports of CND associated with vestibular nerve deficiency, and most such cases were found to have a narrow IAC. However, there are only a few reports of assessment of vestibular function in patients with CND. In this paper, we report a rare case of a patient with CND and vestibular nerve hypoplasia, without a narrow IAC.

　An eight-year-old boy with congenital unilateral profound sensory neural hearing loss in his right ear presented to us with no reaction on auditory brain stem response (ABR) testing and a normal response on otoacoustic emission (OAE) testing. Heavily T2-weighted 3T-MRI showed absence of the cochlear nerve and hypoplasia of the vestibular nerve on the affected side. However, the internal auditory canal was normal in size on both the affected side and the normal side. Vestibular function tests, caloric testing and cervical vestibular myogenic potential (cVEMP) testing revealed vestibular dysfunction, canal paresis and decreased cVEMP reaction in the affected ear. In this paper, we would like to emphasize the necessity of considering the vestibular function in patients with CND, because of the possibility of associated vestibular dysfunction in these patients.

　In cases of “heavy cupula”, the adhesive strength of the otoconia to the cupula or the adhesive side of the cupula is often unclear. To investigate this further, the course after treatment and the natural course were investigated in 31 cases of heavy cupula that we encountered at our clinic over a one-year period. First, the cases were divided into two groups by the responses to the affected-ear-down 135° maneuver; the group with the lateral canal BPPV-canalolithiasis apogeotropic variant (: L-BPPV-Can-a), in which the otoconia came in contact with the cupula on the canal side, and the group with the lateral canal BPPV-cupulolithiasis (: L-BPPV-Cup), in which the otoconia adhered to the cupula. In the L-BPPV-Can-a group, rolling the head and trunk from the affected-ear-down 135° to the supine position caused detachment of the otoconia from the canal side of the cupula and moved them further in the posterior direction. The maximum slow-phase velocity of nystagmus in the healthy-ear-down position to that in the affected-ear-down position (H/A) was examined in both groups. In the L-BPPV-Cup group, the affected-ear-up lateral decubitus method was employed. Sleeping in the affected-ear-up lateral decubitus position all through the night could detach the otoconia from the utricular side of the cupula and restore them back into the utriculus. The H/A in the L-BPPV-Can-a group was significantly greater than that in the L-BPPV-Cup group (P<0.005). Use of the ratio of 2.5 as the cutoff point to distinguish between the two groups was associated with a sensitivity of 0.8 and specificity of 0.8. The affected-ear-up lateral decubitus method was effective in 58% of the cases. The results suggest that among the 31 cases of heavy cupula, there were 13 with the L-BPPV-Can-a variant and 18 with the L-BPPV-Cup, including 4 with the otoconia adhering to the cupula on the canal side, 12 with the otoconia adherent to the cupula on the utricular side, and 2 undetermined.

　There are few reports in Japan of investigation of the effect of vestibular rehabilitation (VR) by physical therapists (PT). This study was aimed at examining the effectiveness of vestibular rehabilitation therapy (VRT) for patients with unilateral peripheral vestibular disorder.

　The subjects were nine patients with chronic unilateral peripheral vestibular disorder. PTs provided VR, consisting of eye movement exercises, body balance exercises, walking exercises, daily activity movement exercises, to the subjects once a month. The subjects were instructed to perform one to three sets of customized home exercises a day. For this study, the results of the Timed Up & Go test (TUG), Dynamic Gait Index evaluation (DGI), Functional Gait Assessment (FGA) and Activities-Specific Balance Confidence Scale evaluation (ABC) conducted before the start of the VRT and at one month, two months and three months after the start of VRT were compared.

　The results revealed a significant difference in the results of the DGI and FGA recorded before the start of the intervention and at three months after the start of the intervention later (p<0.05 for both). In both the DGI and FGA, the number of subjects below the cutoff value for the risk of falls decreased after the intervention. There were no significant differences in the results of the TUG or ABC recorded before and after the start of the intervention, although the number of subjects falling below the cutoff value for the risk of falls decreased in the ABC.

　VR might improve the vestibular function and may need to be continued for more than three months. DGI and FGA were useful for the evaluation of patients with chronic unilateral vestibular disorder. TUG was not suitable for the evaluation of patients with chronic unilateral vestibular disorders with advanced walking ability. Further studies are needed on the usefulness of ABC for the evaluation of these patients.

　Object: To show the effect of Kampo medicine in suppressing fluctuations of the subjective sense of balance in a patient with Meniere's disease.

　Material & Methods: The patient was a 75-year-old man with chronic Meniere's disease. He had been diagnosed as having Meniere's disease nine years earlier, and continued to have vertigo attacks after two surgeries. We instructed the patient to maintain a vertigo diary with a Visual Analogue Scale (VAS) for two years. During one of those two years, we treated him with the Kampo medicine, Ryokeijyutukantou.

　Result: Statistical analysis of the VAS values recorded in the vertigo diary showed that the Kampo medicine was effective at suppressing fluctuations of the patient's subjective sense of balance. By long-term analysis, there is no effect of the weather and pressure to Meniere's disease.

　Discussion: Our findings suggested that the Kampo medicine was effective for suppressing fluctuations of the subjective sense of equilibrium in our patient with Meniere's disease.

　Japan has become a super-aging society, and the number of elderly persons with dizziness is increasing. In addition, elderly persons with dizziness have a high risk of falling, and fractures caused by falls can decrease the life span. It is therefore necessary to take appropriate countermeasures. Treatments for dizziness are wide-ranging and include physical therapy, such as canalith repositioning, and pharmacotherapy. However, many patients do not improve even after these treatments. In this study, we compared the results of stabilometry examined before and after the use of a cane in 21 patients aged 65 years or older with a history of dizziness who visited our department (DHI score of 28 points or higher). The use of a cane improved the following measured parameters: total length of body sway, area of body sway, and unit area body sway length at the time of eye opening and closing. To prevent falling, somatic sense input and skeletal muscle input focused on the lower extremities are important. It is expected that these inputs decline in elderly persons, and based on the results of the current study, it is likely that the use of prosthetics, such as a cane, will play an important role in the future in supporting these subjects.