Actual Exam 1 Flashcards
Which of the following regarding epidemiology and population demographics of dizziness / balance disorders is FALSE?
Dizziness is one of the most common complaints in outpatient clinics
Dizziness is the #1 complaint to medical providers for individuals over 70 years of age
The number of older individuals (those over 65 years of age) is expected to decrease by 2030 driving healthcare costs down
Falls are one of the leading causes of brain injury (TBI) and fractures
50% of individuals over age 70 will experience BPPV at some point
The number of older individuals (those over 65 years of age) is expected to decrease by 2030 driving healthcare costs down
Which of the following statements are TRUE? Select ALL that apply.
Dizziness is a general term which may include descriptions such as lightheadedness, floating, pre-syncope, or loss of equilibrium but without sensation of rotation
Vertigo is a term used to describe sense of rotational movement either of onself (subjective) or one’s surroundings (objective)
Vertigo is more likely to be of central (or non-vestibular) origin whereas “dizziness” is more likely to be of peripheral origin
Many individuals do not fully understand the distinction between dizziness and vertigo therefore it is important to question them about their specific complaint when taking your case history
Imbalance is always peripheral in origin and not likely to be related to central conditions or other factors
Dizziness is a general term which may include descriptions such as lightheadedness, floating, pre-syncope, or loss of equilibrium but without sensation of rotation
Vertigo is a term used to describe sense of rotational movement either of onself (subjective) or one’s surroundings (objective)
Many individuals do not fully understand the distinction between dizziness and vertigo therefore it is important to question them about their specific complaint when taking your case history
Balance depends upon sensory information gathered from what 3 systems?
vestibular, visual, and somatosensory
When discussing vestibular anatomy, “peripheral” refers to which of the following?
Labyrinth & 8th nerve up to the point it enters the brainstem
When discussing vestibular anatomy, “central” refers to which of the following?
Semicircular canals and otolithic organs
Cerebellum only
Brainstem to cortex
Labyrinth & VIIIth nerve up to the point it enters the brainstem
VIIIth nerve and brainstem
Brainstem to cortex
“Vision denied” refers to eyes closed (ENG) or eyes covered (VNG) or the scenario where the patient is without a visible target?
true
What are the two sensory structures within the peripheral vestibluar system and what type of stimuli does each respond to? Be brief but specific.
The first sensory structure is the cristae ampullaris in
The two sensory structures in the peripheral vestibular system are the crista ampullaris and the maculae. The crista ampularis is responsive to angular (rotational) movement and the maculae is responsive to linear (translational) movement and to gravity.
The semicircular canals are located within the membranous labyrinth, contain periplymph and are surrounded on the outside by endolymph and the bony labyrinth?
false
Which the following are TRUE regarding the semicircular canals? Select ALL that apply.
The semicircular canals function in a complimentary or push-pull relationship with the opposite ear
The semicircular canals detect motion in the pitch, yaw and roll planes
The semicircular canals are arranged orthogonal or roughly right angles to each other
The semicircular canals are connected to each other but have no connection with the otolithic organs or rest of the vestibule
The semicircular canals have an enlarged area on both ends called the ampulla and are closed off on one end with no fluid connection to the vestibule
The semicircular canals function in a complimentary or push-pull relationship with the opposite ear
The semicircular canals detect motion in the pitch, yaw and roll planes
The semicircular canals are arranged orthogonal or roughly right angles to each other
Which of the following are TRUE regarding the otolithic organs? Select ALL that apply.
The otolithic organs are arranged perpindicular to each other
The saccule has calcium carbonate particles called otoconia embedded on top but the utricle does not
The utricle is larger and oriented above the saccule which is smaller and oriented below
Unlike the SCCs, the otolithic organs do not possess any vestibular hair cells
Displaced otoconia from the utricular macula is what causes BPPV
The otolithic organs are arranged perpindicular to each other
The utricle is larger and oriented above the saccule which is smaller and oriented below
Displaced otoconia from the utricular macula is what causes BPPV
The semicircular canals work as complimentary pairs during head/body rotation. Match the semicircular canal on the left with its complimentary pair on the right during stimulation.
Left anterior SCC -
Left horizontal SCC -
Left posterior SCC -
Right posterior SCC
Right horizontal SCC
Right anterior SCC
Which of the following statements is FALSE?
The cupula of the SCCs has roughly the same density of the surrounding endolymph and is therefore not sensitive to gravity
Movement of hair cell stereocilia toward the kinocilium results in depolarization and an increase in neural activity
Movement of hair cell stereocilia away the kinocilium results in hyperpolarization and a decrease in neural activity
Movement of hair cell stereocilia toward the kinocilium results in hyperpolarization and an increase in neural activity
There are two types of vestibular hair cells; type I and type II but their exact functional differences aren’t clearly understood
Movement of hair cell stereocilia toward the kinocilium results in hyperpolarization and an increase in neural activity
Movement of hair cell stereocilia toward the kinocilium results in depolarization and an increase in neural activity
For the horizontal SCCs, endolymph movement toward the ampulla (i.e., ampullopetal) results in an __________ response, whereas endolymph movement away from the ampulla (i.e., ampullofugal) results in an __________ response.
inhibitory, excitatory
excitatory, excitatory
inhibitory, inhibitory
excitatory, inhibitory
neutral, excitatory
excitatory, inhibitory
For the anterior and posterior SCCs, endolymph movement toward the ampulla (i.e., ampullopetal) results in an __________ response, whereas endolymph movement away from the ampulla (i.e., ampullofugal) results in an __________ response.
excitatory, inhibitory
inhibitory, excitatory
excitatory, excitatory
inhibitory, inhibitory
neutral, excitatory
inhibitory, excitatory
What are the 3 vestibular reflexes we discussed and give a brief description of the purpose of each.
Vestibulo-ocular reflex (VOR) – generates reflexive eye movement to enable clear vision during head movement
Vestibulocollic reflex (VCR) – acts on the neck musculature to stabilize the head helping to keep the head in horizontal gaze position relative to gravity (accomplished w/ neck musculature rather than eye musculature)
Vestibulospinal reflex (VSR) – generates compensatory body movements to maintain head and postural stability in upper and lower limbs
If an individual was reporting oscillopsia, which vestibular reflex would you expect to be impaired?
vor
What are the 3 cranial nerves involved in eye movement?
Oculomotor (III), Trigeminal (V) and Hypoglossal (XII)
Oculomotor (III), Trochlear (IV) and Abducens (VI)
Oculomotor (III), Vestibulo-cochlear (VIII) and Vagus (X)
Oculomotor (III), Trigeminal (V) and Facial (VII)
Optic (II), Oculomotor (III) and Vagus (X)
Oculomotor (III), Trochlear (IV) and Abducens (VI)
When analyzing nystagmus, we “describe” nystagmus based upon the direction of the fast phase (central component) but “measure” the magnitude of the nystagmus based upon the slow phase (peripheral component)?
true
Which of the following statements is TRUE regarding nystagmus?
Nystagmus beats toward a stimulated ear and away from an inhibited ear
Nystagmus beats toward an inhibited ear and away from an stimulated ear
Nystagmus is independent of stimulation
Rightward (yaw) rotations generate leftward nystagmus
Nystagmus direction is solely dependent upon the neural integrator
Nystagmus beats toward a stimulated ear and away from an inhibited ear
When examining ENG/VNG tracings, which of the following are TRUE?
For horizontal recordings, upward deflections represent rightward eye movements and downward represent leftward eye movements
For horizontal recordings, upward deflections represent lefward eye movements and downward represent rightward eye movements
For horizontal recordings, upward deflections represent rightward eye movements and downward represent leftward eye movements
For paretic lesions, which of the following are TRUE regarding nystagmus?
Nystagmus direction typically has nothing to do with side of lesion
Nystagmus typically beats toward the affected ear
Nystagmus typically beats away from the affected ear
Nystagmus typically beats away from the affected ear
For irritative lesions (like Meniere’s disease), when active, which of the following are TRUE regarding nystagmus?
Nystagmus typically beats toward the affected ear
Nystagmus typically beats away from the affected ear
Nystagmus direction typically has nothing to do with side of lesion
Nystagmus typically beats toward the affected ear
Poorly compensated or decompensated vestibular lesions may sometimes have nystagmus patterns that do not obey the conventional directions?
true
Which of the following regarding vestibular anatomy is FALSE?
There are 2 types of vestibular hair cells; type I (spherical shape) and type II (cylinderical shape) but further differences are not well understood
Otolithic hair cells are arranged in button-like sheets
Hair cells are arranged away from the striola in the utricle and toward the striola in the saccule
Hair cells are arranged toward the striola in the utricle and away from the striola in the saccule
Vestibular hair cells have one tall stereocilia called the kinocilium
Hair cells are arranged away from the striola in the utricle and toward the striola in the saccule
Hair cells are arranged toward the striola in the utricle and away from the striola in the saccule
Match the vestibular structure on the left with the innervating nerve branch on the right.
Anterior Semicircular Canal -
Horizontal Semicircular Canal -
Posterior Semicircular Canal -
Utricle -
Saccule -
Superior vestibular nerve branch
Superior vestibular nerve branch
Inferior vestibular nerve branch
Superior vestibular nerve
Inferior vestibular nerve branch
Which of the following are TRUE regarding ENG/VNG testing? Select ALL that apply.
When analyzing oculomotor normative data you should also visually inspect oculography morphology to confirm abnormal data points actually look abnormal
Poor vision, certain medications and patient arousal / fatigue can affect oculomotor findings
Abnormalities encountered during the oculomotor exam are more likely to be peripheral findings than central findings
Oculomotor abnormalities should be repeatable for them to be considered truly abnormal
If you have 1 or 2 data points in the “abnormal” range, it is still considered an abnormal oculomotor exam
When analyzing oculomotor normative data you should also visually inspect oculography morphology to confirm abnormal data points actually look abnormal
Poor vision, certain medications and patient arousal / fatigue can affect oculomotor findings
Oculomotor abnormalities should be repeatable for them to be considered truly abnormal
Which of the following types of eye movements do we NOT test during ENG/VNG testing?
Saccades
Smooth pursuits
Gaze Holding
Optokinetic (OPK/OKN)
Vergence
Vergence
A patient arrives at your clinic for acute vertigo. Upon examination you note a right-beating nystagmus in center gaze (spontaneous) which increases in magnitude when they gaze to their right and decreases in magnitude when they gaze to their left. What is the phenomena or finding they are demonstrating?
Is this a central sign, a peripheral sign or a non-localizing finding?
Alexander’s Law
peripheral sign
When an individual has a pre-existing nystagmus and gazes in the direction of the fast phase of the nystagmus, the magnitude increases. Gazing away from the fast phase causes it to reduce in magnitude. This is a peripheral sign. It is the ONLY exception to your oculomotor battery which otherwise denotes central findings only.
alexanders
What are the 3 parameters we evaluate when performing saccade testing and what does each measure?
Velocity = speed of eye movement
Accuracy = ability to correctly acquire the target without over or undershooting
Latency = time it takes to acquire the target post-stimulus movement
speed of eye movement
velocity
ability to correctly acquire the target without over or undershooting
accuracy
time it takes to acquire the target post-stimulus movement
latency
What are the two parameters we evaluate when performing pursuit testing and what does each measure?
Gain = eye movement relative to target
Symmetry(phase) = rightward vs leftward comparison
eye movement relative to target
gain
rightward vs leftward comparison
symmetry (phase)
What is the weakest subtest in your oculomotor exam?
OPK/OKN
What is BPPV? How does it occur? Briefly describe the two variants.
Benign Paroxysmal positional vertigo.
Otoconia become dislodged from the utricle and end up in the semicircular canals. Movement of the head causes the otoconia in the canal to move and stimulates the vestibular system causing false sense of vertigo.
“Canalithiasis” or otoconia freely moving in the endolymph and “Cupulolithiasis” or otoconia in contact with the cupula are the 2 types.
Which maneuver is used to EVALUATE FOR anterior and posterior canal BPPV?
Dix-Hallpike maneuver
Pagnini-McClure maneuver
Valsalva maneuver
The BBQ roll
The Trendelenburg maneuver
Dix-Hallpike maneuver
Which maneuver is used to EVALUATE FOR horizontal canal BPPV?
The Dix-Hallpike maneuver
The Supine Head Roll (Pagnini-McClure) maneuver
The Epley maneuver
The Hook maneuver
The Semont maneuver
The Supine Head Roll (Pagnini-McClure) maneuver
What is the most common type of BPPV (variant and which canal) with up to 90-95% of recorded cases?
Posterior canal canalithiasis BPPV
Which of the following maneuvers, that we discussed in class, are used to TREAT anterior/posterior canalithiasis BPPV. Select 2 answers.
The Epley (canalith repositioning) maneuver
The Semont (Liberatory) maneuver
The BBQ roll (Lempert maneuver)
The Valsalva maneuver
The Toynbee maneuver
he Epley (canalith repositioning) maneuver
The Semont (Liberatory) maneuver
Which of the following maneuvers, that we discussed in class, are used to TREAT horizontal canal canalithiasis BPPV.
The Epley (canalith repositioning) maneuver
The Semont (Liberatory) maneuver
The BBQ roll (Lempert maneuver)
The Dix-Hallpike maneuver
The Toynbee maneuver
The BBQ roll (Lempert maneuver)
Eye recording technique that uses changes in the corneo-retinal potential and surface electrodes to track eye movement
EOG/ENG
Eye recording technique that uses pupil localization technology, mirrors and infrared diodes to track eye movements
VOG/VNG
Eye recording technique that uses a metallic loop embedded in the eye or in a tight fitting contact to detect changes in electromagnetic fields and detect eye position
Scleral search coils
Eye recording technique that requires extra time for the eyes to “adapt” to light and darkened environments when goggles open/closed
Eye recording technique that has higher resolution and allows for video playback
VOG/VNG
Vestibular tests are tests of function and can therefore be affected by medications, arousal state and patient effort?
true
List 3 things or questions you would ask a patient who complained of dizziness prior to performing a vestibular evaluation? We discussed several in class. Be brief but specific.
Description = What are you experiencing
Timing = How long does it last when present or is it continuous
Frequency = How often does it occur
Provoking Factors = What causes it
Associated Symptoms
Any Other Medical Hx
Medications
When performing static positional testing, if an individual demonstrates nystagmus what additional actions should you take?
Ask the patient if they are experiencing any subjective dizziness/vertigo
Perform body (lateral) right and left as well to rule out torsion of the neck as contribution to nystagmus
Utilize a visual target for part of the recording to determine if the nystagmus changes in intensity with visual fixation
Wait at least 30 seconds or more to see if the nystagmus fatigues with time or changes direction
All of these choices are correct
all
In the absence of any other abnormality (i.e., normal oculomotor and normal caloric exams), nystagmus observed during static positional testing is considered?
peripheral finding
In order for static positional nystagmus to be considered “abnormal” it has to meet specific criteria. Which of the following is NOT one of those criterion?
Nystagmus is present in ALL positions
Nystagmus changes direction in any single head position or positions
Nystagmus is vertical regardless of intensity
Nystagmus is persistent in at least 3 head positions
Nystagmus magnitude is equal to or greater than 4 deg/sec (VNG), 6 deg/sec (ENG) in any head position
Nystagmus is vertical regardless of intensity
Which of the following is NOT a common feature of posterior canalithiasis BPPV?
Escalation (constant repetition of the offending maneuver will cause the nystagmus to increase on subsequent trials)
Delayed onset latency (nystagmus and vertigo begin after a short interval upon putting patient in offending position)
Duration (nystagmus and vertigo eliminate in 1 minute or less)
Linear rotary direction (nystagmus is up-beating or down-beating torsional)
Reversal (nystagmus may show a milder and reversed direction upon bringing the patient back up post maneuver)
Escalation (constant repetition of the offending maneuver will cause the nystagmus to increase on subsequent trials)
Patient tasking or alerting should be performed during static positional testing?
true
What is the most common bedside exam used to screen VOR function and briefly describe how it is performed. (We did it in lab and watched videos). What would a normal result versus an abnormal result look like?
Halmagyi head thrust or head impulse test.
Clinician grasps patient by the head and uses rapid unexpected head turns to examine the VOR
Patient is asked to keep his/her eyes focused on a target (e.g., clinician’s nose or forehead)
Head should be thrust in the direction of or plane of semicircular canals
Head movement should not exceed 20-30 degrees in any direction but must be high acceleration (>3000 deg/sec/sec)
Head should be held briefly at the end of impulse to monitor for re-fixation saccades
Normal individual will exhibit no corrective / re-fixation saccades and the Impaired individual will exhibit re-fixation saccades in direction of lesion
Name one bedside test that can be used to screen VSR function for postural stability.
fukuda/unterberger
For the phenomena (nystagmus) shown in alexanders, what is the most likely site of lesion?
peripheral finding
Name two types of “normal” physiologic nystagmus.
Endpoint (sustained or unsustained)
Fatigue nystagmus
Optokinetic nystagmus
What was the name of either of the mechanical BPPV treatment devices (pictured below) that we discussed in our BPPV lecture and were featured in the supplementary BPPV videos in your Canvas Readings/Resources (if you viewed them)? The first one received FDA clearance for sale in the United States in 2022. The other device has been around for several years and was endorsed by a prominent otologist.
Omniax - Gyroscopic chir
