Disorders of equilibrium

Question 1

Vertigo

Answer 1

• illusion of movement of the body or environment, sensation,
• a hx finding
• “world spinning around me”, rotating or moving of the room / world
• classified as peripheral or central
• peripheral indicates inner ear or CN VIII problem
• central problem from brainstem, cerebellum (not usually as extreme)

Question 2

Ataxia

Answer 2

• incoordination or clumsiness of movement, motor problem, not weakness
• physical finding, may result from vertigo or other causes

Question 3

Syncope

Answer 3

• sensation of light-headedness
• faintness or giddiness w/o illusion of movement
• decreased supply of blood, O2, or glucose to brain
• typically vague presentation
• at extreme, lose consciousness & called snycope
• AKA falling out or fainting

Question 4

Cardiac dizziness / syncope

Answer 4

• rhythm disturbances or BP disturbances or mechanical problems (aortic stenosis, hypertorphic obstructive cardiomyopathy)
• may have hx of some cardiac abnormality (heart disease, abnormal ECG, echocardiogram, or stress test)

Question 5

Neurologic dizziness / syncope

Answer 5

• when stand up blood pools in legs, supposed to get reflex increase in heart rate and vasoconstriction so more blood goes to head
• w/ neurolgoic syncope instead get excess vagal stimulation, bradycarida and vasodilation - no blood to head = faint
• subtypes: orthostatic hypotension, vasomotor syncope, postmicturition syncope

Question 6

Orthostatic hypotension

Answer 6

• BP drops too much and can’t increase heart rate fast enough
• more in elderly, DM, on diuretics, alpha adrenergic blockers, anticholingerics

Question 7

Vasomotor / Vasovagal Syncope

Answer 7

• by far the most common type of syncope
• sudden increase vagal tone causes syncope by BP drop (stressful or painful situations)
• if a classic hx and attributable to situation minimal workup needed

Question 8

Postmicturition syncope

Answer 8

• Classicall increased vagal tone from urination causes syncope
• defecation/constipation: increased intraabdominal pressure - carotid body stimulation
• if you do Valsalva maneuver you get increased pressure on chest which increases pressure on carotid body - kicked in vagal response

Question 9

Syncope clinical signs and sx

Answer 9

• abrupt onset LOC, lasting for seconds to a few minutes and full recovery
• no post-ictal-like states (as in seizures)
• usually only very mild sx of disorientation (“how did I get on the floor?”)
• no confusion/fatigue

Question 10

Syncope PE

Answer 10

• do orthostatic BP

- cardiac and vascular exams looking for disease

Question 11

Syncope diagnostic tests

Answer 11

• not really needed for easily explained vasovagal syncope, unless recurrent and frequent
• ECG: look for arrhythmias, prolonged QT, signs of infarction or hypertrophy
• autonomic testing: tilt table testing looks for orthostatic hypotension
• electrophysiologic studies: as last resort - invasive studies of electricity of the heart

Question 12

Syncope tx

Answer 12

• tx underlying disease
• check state for driving recommendations for unexplained syncope
• if it doesn’t fit a reassuring pattern, consider workup for dangerous causes

Question 13

Stable stance

Answer 13

-need intact cerebellum, vestibular system, and sensation (vision and proprioception)

Question 14

Classifications of ataxia

Answer 14

• vestibular
• cerebellar
• sensory (propioceptive - vision problems)
• need to figure out which kind as it directs tx

Question 15

Vestibular ataxia

Answer 15

• same lesions that cause peripheral vertigo
• have abnormal stance or gait
• feel unsteady, but don’t fall down
• Romberg: stands okay with eyes open, not as good when closed (positive: when they wobble so much they need to take a step or fall down)
• can get mild vestibular ataxia with middle ear effusion or infection

Question 16

Cerebellar ataxia

Answer 16

• lesions of cerebellum or its connections
• see GREATEST ABNORMAL MOVEMENTS here w/ irregular rate, rhythm, amplitude or force of voluntary movements
• hard time standing with eyes open or close
• positive Romberg
• bad ataxia
• lack control of voluntary movement

Question 17

Sensory ataxia

Answer 17

• if lose proprioception become ataxic
• deficits most often in bilat peripheral nerves or posterior columns of spinal cord
• stand ok with eyes open, close eyes and fall
• decreased joint position sense and vibratory sense are diminished
• use a turning fork to test position sense though vibrations (big tuning fork)

Question 18

Other abnormalities in cerebellar disease

Answer 18

• hypotonia: poor posture, limbs easily moved by small force
• incoordination: acceleration and deceleration of movement decreased, jerky appearance, see best in walking
• eye movements: nystagmus, gaze paralysis or decreased pursuit movements

Question 19

BPPV

Answer 19

• benign paroxysmal positional vertigo
• problems with otoliths in semicircular canals
• always associated with nystagmus (horizontal only)
• benign, common, but scary
• antiemetics, ototlith repositioning, habituation

Question 20

Labyrinthine problems

Answer 20

• Meniere disease: triad (vertigo, hearing loss, tinnitus) and “drop attacks” - unable to stand (ataxic)
• vestibular neuronitis - mostly just vertigo
• labyrinthitis: multiple infectious causes with vertigo and hearing loss

Question 21

Central vertigo

Answer 21

• often heralds more serious neurologic problem
• usually from lesions that affect the brainstem vestibular nuclei or their connections
• central vertigo may occur with or without nystagmus
• if nystagmus is present it can be vertical, unidirectional, or multidirectional and may different in character in the two eyes

Question 22

Peripheral vs. Central vertigo

Answer 22

• Peripheral: intermittent vertigo (severe), nystagmus always present, hearing loss often present, brainstem/ cerebellar signs absent
• central: constant vertigo (less severe), nystagmus may be absent, hearing loss rarely present, brainstem/cerebellar signs present

Question 23

Weak, dizzy, lightheaded (WDL) hx

Answer 23

• how did it occur (sudden onset cerebellar (ataxia) suggest stroke)
• when did it occur? (changes in head or body position)
• describe sensation (does room spin, do you feel unsteady when walking, etc)

Question 24

weak, dizzy, lightheaded PE

Answer 24

• vital signs and orthostatics
• general: signs of other illness
• HEENT: inner ear or hearing loss, Dix-Hallpike, nystagmus
• CVD
• complete neuor exam (abnormality suggest cerebellar origin)

Question 25

Motor

Answer 25

Gait: any ataxia, wide base and unsteady

• cerebellar: look drunk, wide based, and staggering, tandem walking always impaired
• sensory: lift feet high off ground and slap down heavily (steppage gait)
• coordiante: leg ataxia or arm ataxia
• leg ataxia: run heel up and down other leg
• arm ataxia; irregular force, rate, rhythm, amplitude of rapid successive tapping