Approach to Equilibrium Disorders Flashcards
what PE test is key in diagnosing an equilibrium disorder?
romberg maneuver
who is predisposed to an equilibrium disorder?
elderly
chronic illness
certain meds
what is vertigo?
the illusion of movement of oneself or objects due to vestibular or neurologic dysfunction
what is disequilibrium?
may or may not be caused by vertigo
altered static or dynamic balance due to dysfunction of cerebellum, dorsal columns, motor systems, or basal ganglia
what is presyncope?
lightheadedness or impending LOC often due to orthostasis, arrhythmia, or hyperventilation
aggravated by heat, prolonged standing or large meals
what symptoms may be associated with vertigo?
sweating
nausea
hearing impairment
tinnitus
what type of disequilibrium will be associated with a positive romberg sign?
sensory
what symptoms may be associated with presyncope?
pallor
sweating
visual dimming/constricted fields
weakness
what are characteristics of peripheral vertigo?
intensive symptoms brief, fixed, horizontal nystagmus intense N/V possible hearing loss no neuro sx
what are characteristics of central vertigo?
mild sx
persistent, changeable, vertical nystagmus
mild N/V
neuro sx present
what are causes of peripheral vertigo?
BPV Vestibular neuronitis Meniere's disease superior canal dehiscence mal de debarquement drug-induced ototoxicity
which type of BPV is most common?
posterior
what maneuver can induce posterior BPV?
Dix Hallpike with the affected ear facing down
what maneuver can induce anterior BPV?
Dix Hallpike with affected ear facing up
what maneuver can induce horizontal BPV?
supine roll test (Pagnini-McClure)
what is the treatment for BPV?
may resolve spontaneously
positional exercises (Semont Maneuver)
medications
PT
what is vestibular neuronitis?
spontaneous attack of vertigo that does not involve hearing loss or tinnitus and is not positional
what are the symptoms of vestibular neuronitis?
vertigo, N/V peaking within 24 hours and lasting for days to weeks
what is the etiology of vestibular neuronitis?
inflammatory CN VIII lesion
what is the treatment for vestibular neuronitis?
resolves spontaneously
steroids may be helpful
what is Meniere’s disease?
recurrent episodes of spontaneous vertigo lasting more than 20 mins but less than 24 hours
what are the other symptoms of Meniere’s disease?
low-frequency hearing loss
tinnitus
aural fullness
what is the etiology of Meniere’s disease?
increase in the volume of labyrinthine endolymph because of poor absorption
what is the treatment for Meniere’s disease?
sodium restriction
diuretics
surgery for decompression
what is superior canal dehiscence?
episodic vertigo caused by thinning of bone that separates the superior canal from middle fossa creating a third inner ear window
triggered by loud noises or pressure
how is superior canal dehiscence diagnosed?
based on symptoms
MRI
what is the treatment for superior canal dehiscence?
surgery to resurface superior canal
avoid triggers
what is mal de debarquement?
“sickness of disembarkment”
the illusion of movement as an aftereffect of travel
what are the symptoms of mal de debarquement?
rocking, swaying feeling occuring almost immediately after cessation of the precipitating event
lasts less than 24 hours
what is the treatment for mal de debarquement?
meclizine
scopolamine
benzos
what is required for the diagnosis of vestibular migraine?
at least 5 episodes of moderate/severe vestibular sx lasting minutes to hours
current or previous hx of migraine
one or more migraine features with at least 50% of episodes
unaccounted for by other dx
what is the HINTS test and what is it used for?
“head impulse-nystagmus-test of skew”
helps distinguish brainstem lesion vs peripheral lesion in a patient with an acute vestibular syndrome
higher sensitivity than MRI to detect acute stroke
what is considered an abnormal HINTS?
abnormal VOR reflex (head impulse)
vertical or horizontal nystagmus
uncover/cover test skew
what metabolic disorders can cause disequilibrium?
vit B12 deficiency
hypothyroid
wilson disease
what neoplasms can cause disequilibrium?
cerebellopontine angle tumor:
acoustic neuroma (Schwannoma)
meningioma
cholesteatomas
what are the signs of neoplastic disequilibrium?
hearing loss absent corneal reflex tinnitus facial pain/sensory loss facial droop
what is paraneoplastic cerebellar degeneration?
remote effect of systemic cancer due to antibodies to tumor cell antigens that cross-react with cerebellar Purkinje cells
what are the most common hereditary spinocerebellar ataxias?
SCA 1 = olivopontocerebellar
SCA 3 = Machado-Joseph
what are the symptoms of spinocerebellar ataxias?
slowly progressive cerebellar ataxia of limbs + brainstem signs + peripheral neuropathy
what is Friedrich’s ataxia?
AR disorder due to mutation on Ch. 9
sx onset before age 20 gait ataxia dysarthria impaired leg sensation muscle weakness absent DTRs in legs
what are the secondary features of Friedrich’s ataxia?
extensor plantar responses pes cavus scoliosis cardiomyopathy optic atrophy nystagmus
what is LOFA?
Late onset freidrich’s ataxia
onset after 25 y/o
how does LOFA differ from FA?
in LOFA: LE spasticity or retained reflexes fewer cardiac abnormalities fewer skeletal abnormalities cerebellar atrophy on MRI longer life span
what is ataxia telangiectasia?
AR disorder due to mutation on Ch. 11
progressive pancerebellar degeneration beginning in infancy
what are the hallmarks of ataxia telangiectasia?
progressive ataxia
oculocutaneous telangiectasia
immune deficiency
what is spondylotic myelopathy?
nonspecific degenerative changes of the spine due to disk and/or joint disease and/or hypertrophy of spinal ligaments
what are the symptoms of spondylotic myelopathy?
unexplained gait impairment or imbalance sensory symptoms in legs bladder dysfunction spasticity hyper reflexive DTRs Babinski signs
what neuro signs are present with B12 deficiency/combined systemic degeneration?
gait and balance problems distal sensory loss babinski signs romberg sign \+/- lhermitte sign
what vitamin deficiency can mimic Freidrich ataxia?
Vitamin E def
what toxin can cause B12 deficiency and therefore cause disquilibrium?
nitrous oxide
