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Neuro II > Clinical Vestibular Disorders > Flashcards

Clinical Vestibular Disorders Flashcards

1
Q

What are the components of the peripheral vestibular system?

A
  • 3 paired semicircular canals
  • otolithic (macular organs)
    • utricle
    • saccule
  • cristae
    • end organs containing hair cells w/in ampullated portion of membranous labyrinth
  • cupula
    • gelatinous matrix where cilia of hair cells are embedded
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2
Q

What are otoliths?

A

blanket of calcium carbonate of crystals that are present only in the otolithic organs (not in SCCs) - move, depolarize & tell your brain that your head is moving

L & R eats are complimentary, not identical

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3
Q

Which nerve is the afferent connection from the peripheral vestibular system to the brain stem nuclei?

A

vestibular nerve

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4
Q

Which nerve goes to the superior and horizontal SCCs & utricle?

A

superior vestibular nerve

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5
Q

Which nerve goest to the posterior SCC & urticle?

A

inferior vestibular nerve

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6
Q

What is the vestibular ocular reflex (VOR)?

A

nystagmus

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7
Q

What is the illusion of rotational, linear, or tilting movement of self (subjective) or environment (objective)?

A

vertigo

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8
Q

What is the sensation of instability?

A

disequilibrium

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9
Q

What is the inability to focus on objects during head movement?

A

oscillopsia

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10
Q

What is the sense of impending faint, presyncope?

A

lightheadedness

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11
Q

What is the difference between physiologic dizziness & multisensory dizziness?

A
  • physiologic: motion sickness, dizziness in heights
  • multisensory: deterioration/degeneration in multiple sensory systems responsible for balance often related to age, diabetes, stroke, etc.
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12
Q

What are questions you should as when taking the history on a patient you expects has a vestibular condition?

A
  • duration of attack
  • frequency
  • effect of head movements
  • inducing posture or position
  • associated aural symptoms
  • concomitant or prior ear disease/surgery
  • family history
  • head trauma
  • medications
  • comorbidities
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13
Q

What is a positive head shake test?

A

shake head for 15 seconds

(usually) head shake nystagmus (HSN) away from involved ear

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14
Q

Atypical (vertical or rotary) nystagmus requires what type diagnosis exclusion?

A

CNS disorder

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15
Q

What is the test for VOR?

A

halmagyi (horizontal high-frequency head thrust)

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16
Q

What is a positive oscillopsia test?

This suggests what diagnosis?

A

loss of dynamic visual acuity

loss of lines of Snellen chart with rapid horizontal head shaking - suggests bilateral vestibular loss

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17
Q

What is a positive VOR suppression test?

Suggests what diagnosis?

A

inability to visually suppress nystagmus during head rotation

suggest defect of vestibulocerebellum

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18
Q

What is the cardinal sign of vertigo?

A

nystagmus

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19
Q

What is nystagmus?

A

slow phase is direction of endolymph (vestibular origin)

the quick phase (central origin) is compensatory

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20
Q

What is physiologic nystagmus?

A

end-point nystagmus on lateral gaze greater than 30 degrees

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21
Q

What is spontaneous nystagmus?

A

nystagmus without positional or labyrinthine stimulation

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22
Q

What is induced nystagmus?

A

nystagmus induced by stimulation

caloric, rotation, positional, etc.

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23
Q

What is Ewald’s law?

A

eye & head movements occur in the plane of the canal being stimulated & in the direction of the endolymph flow

ampullopetal flow stimulates the lateral canal- ampullofugal inhibits (reverse is true in posterior & superior)

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24
Q

What is Alexander’s law?

A
  • amplitude of nystagmus increases when the eyes look in the direction of the fast phase
    • first degree: present only when gazing in fast component direction
    • second degree: 1st degree plus straight gaze
    • third degree: present in all 3 directions
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25
Q

What are the components of a vestibular physical examination?

A
  • HEENTN
  • audiometric evaluation
  • gait/walking
  • cerebellar testing
  • hyperventilation test
  • pneumatic otoscopy
  • Dix-Hallpike Test
  • Head Thrust Test/Head Shake Test
26
Q

In what situations is laboratory vestibular testing indicated?

Purpose?

A
  • Indication: site/side of lesion not identified
    • ascertain benefit of vestibular rehab
    • assess recovery of vestibular function
    • assess contralateral function if destructive procedure is contemplated
    • determine if intervention has been successful
27
Q

What is electronystagmogrphy?

A

horizontal & vertical eye movements are recorded (ENG-electrodes or VNG-video)

28
Q

What is a bithermal caloric test?

Use to identify?

A

evaluation of the horizontal SCC with cold & warm water in caloric test position (COWS)

can identify unilateral weakness or bilateral weakness

29
Q

What is the purpose of a rotational chair test?

A

identify residual function in patients with no calorics

30
Q

What is the Scleral Search Coil & why would you perform this test?

A

direct contact with the globe of the eye

gold standard measurement technique for eye movement

31
Q

What is a vestibular-evoked myogenic potential & why would you perform this test?

A

sound stimulates saccule with reflex loop to SCM

increased in middle ear pathology

decreased in SCDS, perilymphatic fistula

32
Q

What is the most common cause of vertigo?

A

posterior SCC

(benign paroxysmal positional vertigo)

33
Q

What is the mechanism causing benign paroxysmal positional vertigo?

A

utricular degeneration or trauma liberates otoconia that float toward ampulla of PSCC

34
Q

What are the symptoms seen in Benign Paroxysmal Positional Vertigo?

A

severe positional vertigo with change in head position lasting seconds

spontaneous resolution within months (most cases)

35
Q

What is the diagnostic maneuver for benign Paroxysmal Positional Vertigo? Positive test?

A

Dix-Hallpike maneuver

  • lying on back with head turned to one side (repeat for other side)
    • positional rotational/torsional nystagmus toward the affected ear
    • latency of onset (seconds)
    • short duration (less than one minute)
    • fatigue on repeated testing
36
Q

What drugs may give a false negative Dix-Hallpike maneuver?

A

vestibular suppressants

sedating antihistamines & benzos (block VOR)

37
Q

What is the treatment for Benign Paroxysmal Positional Vertigo?

A

Epley Maneuver / Semont Maneuver

38
Q

Meniere Disease (aka?) is characterized by what features?

Symptoms?

A

Idiopathic Endolymphatic Hydrops

bowing & rupture of Reissner’s membrane with a mix of endolymph & perilymph

Symptoms: attacs of tinnitus, vertigo, aural fullness & hearing loss lasting minutes - hours

39
Q

What are otolithic crisis of Tumarkin?

A

“drop attacks” with sudden falls without vertigo or LOC

40
Q

What is Lermoyez variant?

A

progressive hearing loss & aural fullness that resolves with onset of vertigo

41
Q

What is cochlear hydrops?

A

fluctuating hearing loss, aural fullness & tinnitus without vertigo

42
Q

What type of nystagmus is seen with Meniere Disease?

A

direction of nystagmus varies over time with course of attack

43
Q

What are the results of an audiogram performed for a patient with Meniere Disease?

A

low frequency SNHL that fluctuates over time

44
Q

What are the results of an ENG for a patient with Meniere Disease?

A

unilateral weakness

45
Q

What is the treatment for Meniere Disease?

A
  • Diet:
    • low salt, no caffeine/stimulants
  • Diuretics
  • Vestibular suppressants:
    • antihistamines & benzodiazepines
  • Surgery
    • endolymphatic sac decompression
    • gentamicin ablation
    • neurectomy
    • labyrinthectomy
46
Q

What is Cogan Syndrome? Symptoms?

A

autoimmune disease:

interstitial keratitis, bilateral rapidly progressive audiovestibular dysfunction & multisystem vasculitis

bilateral progressive hearing loss → progress to complete absence of vestibular function

47
Q

Treatment for Cogan Syndrome?

A

high-dose steroid or cyclophosphamide

48
Q

What is Recurrent Vestibulopathy?

A

recurrent attacks of episodic vertigo similar to MD without auditory or neurological dysfunction

49
Q

What are the possibilities of progression for a patient with Recurrent Vestibulopathy?

A

8.5 years

  • 60% → remission
  • 15% → Meniere’s Disease
  • 10% → continued active attacks
  • 10% → BPPV
  • 5% → other peripheral symptoms
50
Q

What is Vestibular Neuronitis?

A

Dramatic sudden vertigo and vegetative symptoms lasting days to weeks with gradual improvement

absence of auditory dysfunction

51
Q

How do you differentiate Vestibular Neuronitis from Labyrinthitis?

A

Labyrinthitis also has auditory dysfunction

52
Q

What type of nystagmus is seen with Vestibular Neuronitis? Response to caloric test?

A

fast phase nystagmus away from involved side

hypofunction in response to caloric test

53
Q

What is the treatment for Vestibular Neuronitis? If no improvement?

A

supportive for vertigo & vegetative symptoms

failure to improve over 2-3 weeks requires a CNS lesion to be excluded (MRI w/ contrast +/- ENG)

54
Q

What is Traumatic Perilymphatic Fistula? Symptoms?

A

abnormal communication between perilymphatic space and middle ear

varying symptoms from episodic vertigo, positional vertigo, motion intolerance ; disequilibrium following increases in CSF pressure (valsalva), nose blowing or lifting (Hennebert phenomenon) or exposure to loud noises (Tullio phenomenon)

55
Q

What are the possible causes of traumatic perilymphatic fistula?

A

barotrauma, penetrating trauma, surgical trauma (stapes), cholesteatoma, penetrating trauma, physical exertion

56
Q

What is the positive fistula sign?

A

nystagmus to affected ear with ear pressure

57
Q

What is the treatment for traumatic perilymphatic fistula?

A

bedrest with elevated HOB

laxatives

consider surgical exploration & patch

58
Q

What is superior canal dehiscence syndrome?

A

form of inner ear fistula with communication between middle cranial fossa & superior SCC

creates a third mobile window within the canal with abnormal endolymphatic flow

59
Q

What are the symptoms of superior canal dehiscence syndrome? Treatment?

A

sound & pressure evoked vertigo, hyperacusis, gaze-evoked tinnitus, chronic disquilibruim, positive VEMP

surgical repair

60
Q

Diagnosis of migraine-associated vertigo requires what sign? Treatment?

A

close temporal associate of both conditions

antimigraine therapy

61
Q

Cervicogenic vertigo causes what

A

vascular compression

abnormal sensory input from neck proprioceptors

cervical cord compression stenosis

CSF leak

high cervical disease (C1-C2)

62
Q

Check out / write out this diagram (if you find it helpful)

A

nice job!

Neuro II (30 decks)

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