Clinical Approach to Equilibrium Disorders

Question 1

Disequilibriums:

Sensory
Motor
Cerebellar

Answer 1

Sensory: worse in dark and + Romberg sign.
Motor: mechanical, peripheral, motor, cerebellar cause; no Romberg.
Cerebellar: no Romberg.

Question 2

BPPV presentation:

Answer 2

Brief recurrent episodes of vertigo triggered by changes in head position w/ respect to gravity.

Due to otolith dislodging.

Question 3

What maneuver is done to trigger/test for BPPV?

Answer 3

Dix-Hallpike

Question 4

Dix-Hallpike can only be used for:

It cannot be used for:

Answer 4

Episodic vertigo

If the patient has spontaneous vertigo

Question 5

What test is done if a lateral (horizontal) canal lesion is suspected?

Which side is defective?

Answer 5

Supine roll test

Side with the most prominent nystagmus is the affected horizontal semicircular canal

Question 6

Treatment for BPPV

Answer 6

May resolve spontaneously
Positional exercises
Vestibular suppressants - meclizine, etc.
Antiemetics
Anxiolytics
PT

Question 7

Semont maneuver

Answer 7

Helps w/ BPPV

Rotate 45 deg. and lay over to the left, then to the right

Question 8

Vestibular neuronitis presentation:

Cause:

Progression:

Answer 8

Spontaneous attack of vertigo that does not involve hearing loss or tinnitus and is not positional.
Acute vertigo, N/V peaking within 24 hrs and lasting for days to wks.

Inflammation of CN 8 (?viral).

Resoves spontaneously, steroids may help.

Question 9

Meniere disease onset:

Which sex is more likely?

Cause:

Answer 9

20-50 y/o

Female 3x more likely

Increased volume of endolymph due to poor absorption (endolymphatic hydrops)

Question 10

Presentation of Meniere disease (4)

Answer 10

Recurrent episodes of spontaneous vertigo (> 20 min, typically hrs, but less tan 24 hrs) with subsequent dysequilibrium.

Low frequency hearing loss.

Tinnitus

Aural fullness

Question 11

Meniere disease treatment for…

Symptomatic
Na+ restriction
Diuretics
Surgery

Answer 11

Symptomatic - lorazepam, diazepam
Na+ restriction - 1.5-2 g/day
Diuretics - thiazides, furosemide
Surgery - endolymphatic sac decompression

Question 12

Superior canal dehiscence cause:

Symptoms

Triggers

Dx

Tx

Answer 12

Thinning of bone that separates superior canal from middle fossa effectively making a 3rd inner ear window.

Episodic vertigo, nystagmus, chronic dysequilibrium

Loud noises, pressure in external auditory canal

Symptomology, MRI can help

Avoid triggers, maybe surgery

Question 13

Mal de Debarquement symptoms:

Cause

Tx

Answer 13

Illusion of aftereffect travel (sea, car etc) - rarely true vertigo. < 24 hrs.

Failure of brain function to readapt to a movement once it stops.

Meclizine, Scopolamine, Benzos.

Question 14

Requirements for Dx of Vestibular Migraine (4)

Answer 14

> 5 episodes of mod/severe vestibular symptoms > 5 min to 72 hrs.

Current or previous h/o migraine w/ or w/o aura.

1 or more migraine features with at least 50% of episodes: HA, photophobia, phonophobia, nausea, visual aura.

Uncounted by another dx.

Question 15

Vascular (ischemic) vertigo =

More common in:

Cause:

Answer 15

CENTRAL cause: repeated episodes of isolated vertigo w/o other neurological symptoms should always suggest a non-neuro cause. However, it almost aways comes w/ other neuro sx.

Elderly

Ischemia to labyrinth, brainstem or both.

Question 16

HINTS test is used for:

It is abnormal if: (3)

Answer 16

Distinguishment of brainstem lesion (stroke) from peripheral lesion in a patient w/ acute vestibular syndrome

Abn:

• normal head impulse nystagmus (HIT)
• bidirectional or direction changing nystagmus
• presence of skew deviation