Exam 2: Vestibular Examination Flashcards
What are the four main vestibular diagnoses?
- BPPV
- Unilateral hypofunction
- Bilateral hypofunction
- Central
What is the definition of VOR?
Maintains stability of an image on the fovea of the retina during rapid head movements
What direction do the eyes and head move during VOR?
Eyes will more the opposite of the head
What is the definition of VOR Gain?
Relationship of eye velocity to head velocity – head and eyes move in opposite directions are equal speeds
What is the definition of VOR Phase?
Relationship of amplitude between the eyes and head – equal
What value is considered a healthy VOR Phase?
0 Phase Shift
What is the Inhibitory Cut-Off?
Inhibition can only be recorded to a firing rate of 0
Describe an intact inhibitory cut-off
When you turn your head quickly to the right, the right vestibular system is responsible for detecting the change
Describe an impaired inhibitory cut-off
When you turn your head quickly to the right, the right side vestibular system is not able to excite to the capacity it needs to
The opposite side cannot help because it is inhibited at 0 spikes/second
What is the definition of UVH?
One vestibular apparatus is hypofunctioning with a low tonic firing rate
What are common diagnoses that can lead to UVH?
Vestibular neuritis, labyrinthitis, Meniere’s, Perilymph Fistula, Vestibular Schwannoma/Acoustic Neuroma, chronic BPPV
What percentage of people will experience a fall since the onset of UVH?
30%
What are the two possible vestibular dysfunction that can result from an infection?
Vestibular neuritis or labyrinthitis
What is vestibular neuritis?
Inflammation of the vestibular part of the nerve that results in vertigo only
What is vestibular labyrinthitis?
Inflammation of both branches of CN VIII that results in vertigo and hearing loss
Differentiate between the symptoms of vestibular neuritis and labyrinthitis
Neuritis only results in vertigo while labyrinthitis results in vertigo and hearing loss
What is Meniere’s Disease?
Abnormal fluctuations in endolymphatic fluid
What population is more likely to develop Meniere’s?
Females between 40-60
How long does a Meniere’s flare up last?
2-4 hours
What are symptoms of Meniere’s?
Low frequency hearing loss, episodic vertigo, sense of fullness in ears, tinnitus, nausea and vomitting
Is is recommended to perform vestibular rehab during a Meniere’s flare up?
No – it is contraindicated
What can result from chronic Meniere’s Disease?
UVH, will require rehab
What is the treatment for Meniere’s Disease?
Balance fluids by reducing fluid buildup, reduced sodium diet, avoid caffeine, alcohol, and smoking, surgical intervention
What is a Perilymph Fistula?
Rupture of the oval or round window that separates the middle from the inner ear
What can cause a Perilymph Fistula?
Excessive pressure changes, blunt head trauma, extremely loud noises
What is the pathophysiology associated with a Perilymph Fistula?
Perilymph fluid leaks into the middle ear
What are symptoms associated with a Perilymph Fistula?
Vertigo and hearing loss
What is the treatment for a Perilymph Fistula?
Rest, surgical repair, followed by vestibular rehab
Should you perform vestibular rehab for a Perilymph Fistula prior to surgical repair?
No
What is a Vestibular Schwannoma
Benign tumor of the Schwann cells that compresses CN VIII
What other nerve can be implicated with a Vestibular Schwannoma?
CN VII
What symptoms are associated with a Vestibular Schwannoma?
Unilateral hearing loss, tinnitus, vertigo
What is the treatment for a Vestibular Schwannoma?
Surgical excision followed by vestibular rehab
What are the acute symptoms associated with UVH?
Vertigo, nausea, spontaneous nystagmus, oscillopsia, disequilibrium, gait, posture
What timeframe is considered acute in relation to UVH symptoms?
Two weeks
What are sub-acute and chronic symptoms of UVH?
Gait instability, oscillopsia, head movement induced symptoms
What symptoms should have resolved as UVH progresses to a more chronic presentation?
Reduction of nystagmus and nausea due to the spontaneous rebalancing of the resting tonic firing rate
What direction is oscillopsia in?
Vertical
What is the cause of spontaneous nystagmus?
Brain stem is receiving greater afferent input from the intact labyrinth so it responds by generating nystagmus that the patient then interprets as vertigo
How is nystagmus named?
By the fast phase
If the fast phase of spontaneous nystagmus is directed left, which is the “good” and “bad” side?
Good side = left
Bad side = right
What is BVH?
Reduced of absent function of both peripheral vestibular sensory organs and/or nerves
What are common diagnoses that can lead to BVH?
Idiopathic, ototoxicity, meningitis, autoimmune disorders, bilateral Meniere’s, vestibular neuritis, neurotoxicity from cancer treatment, TIA of blood vessels, bilateral Schwannoma
How can ototoxicity lead to BHV?
Certain classes of antibiotics are gradually taken up by the hair cells and continue to build in the system rendering the cells unable to respond accurately to head movement
What are the two main types of drugs that can lead to ototoxicity?
Aminoglycosides, chemotherapy
What symptoms are associated with BVH?
Imbalance, gait ataxia, oscillopsia that causes decreased visual acuity with head movement, difficulty walking in the dark and on uneven surfaces
What percentage of people will fall since their onset of BVH?
50%
Are people more likely to fall with UVH or BVH?
BVH (50%) > UVH (30%)
Will patients have vertigo or nystagmus with a diagnosis of BVH?
No because both sides are affected, so there is no imbalance to cause the symptoms
What is Central Vestibular Dysfunction?
Pathology of the vestibular system proximal to the vestibular nuclei that begins in the brainstem and connects to the reticular formation, thalamaus, cerebellum, and cortex
What are common diagnoses associated with Central Vestibular Dysfunction?
AICA and PICA stroke, TBI or concussion, MS, Multiple System Atrophy, cerebellar pathology, migraine related dizziness, brain tumor
What three main strokes can be associated with Central Vestibular Dysfunction?
AICA, PICA, Vertebral artery
How will Central Vestibular Dysfunction present if it is caused by MS?
Affects CN VIII at the brainstem and will present like UVH
What is Multiple System Atrophy and what are associated symptoms?
Progressive degenerative disease of the nervous system.
Symptoms include cerebellar ataxia, autonomic dysfunction, Parkinson’s like symptoms, CST dysfunction, dizziness and imbalance
What are symptoms of migraine related dizziness?
Vertigo, dizziness, imbalance, motion sickness, nystagmus
Describe nystagmus with a Central Vestibular Dysfunction
Pendular, will oscillate without a slow or fast phase, bidirectional nystagmus on lateral gave, unable to stop with visual fixation
What main symptoms will be present with a Central Vestibular Dysfunction?
Nystagmus, vertigo, dysequilibrium, balance deficits, laterpulsion, head tilt, oculomotor dysfunction, perceptual deficits. Some dysphasias.
What is laterpulsion?
Tendency to fall to one side
What are some conditions that can present like Central Vestibular Dysfunction?
Motion sickness, Mal de Debarquement, cervicogenic dizziness, psychiatric disorders
What is Mal de Debarquement?
Feeling sick upon disembarkment and reporting persistent rocking and swaying at rest that will resolve during motion. Lasts more than 24 hrs
Describe cervicogenic dizziness
From the cervical spine or surrounding soft tissue. Affects proprioceptive input and alters afferent input
How should you treat cervicogenic dizziness?
Address musculoskeletal impairments first before doing vestibular rehab
What diagnosis is being described?
Unidirectional nystagmus with a slow and fast phase, intense vertigo that can last hours to days, dysequilibrium, oscillopsia
Unilateral Vestibular Hypofunction
What diagnosis is being described?
No nystagmus or vertigo, dysequilibrium and oscillopsia
Bilateral Vestibular Hypofunction
What diagnosis is being described?
Vertical nystagmus, mild vertigo, dysequilibrium, ataxia, neuro findings
Central Vestibular Dysfunction
What is happening during a retinal slip?
When you turn your head to try and maintain focus, it gets blurry because the image moves off of the retina
What are red flag signs during vestibular sceening?
Unilateral hearing loss, discharge of fluid from the ear, syncope with lightheadedness, alterations in consciousness, positive VBI, new onset of neuro tests of central pathology
What could unilateral hearing loss that is not associated from Meniere’s be the result of?
Schwannoma or AICA stroke
What cranial nerves does smooth pursuits test?
III, IV, VI
What is the purpose of performing smooth pursuits?
Rule out central pathology
Describe how to perform smooth pursuits
Move the tip of a pen in all directions (H)
What is a positive finding with smooth pursuits?
Patient is unable to follow the target, catch-up saccades, diplopia
What does a positive finding with smooth pursuits indicate?
Central lesion, CN III/IV/VI lesion, acute peripheral nerve impairment
What is the purpose of testing saccades?
Coordination and ocular metria assessment
Describe how to perform a saccades assessment
Hold two fingers at eye level in front of patient. Have them look from one finger, to your nose, to the other finger and back as fast at they can. Perform both horizontally and vertically
What are positive findings during a saccades assessment?
Dysmetria, hypometria, hypermetria
What does a positive saccades test indicate?
Central lesion or acute peripheral nerve impairment
Describe how to test for convergence
Hold a pen at eye level and slowly bring it toward the patient’s nose. Have them tell you to stop when they see two distinct images and measure the distance to their nose
What distance is considered abnormal when testing convergence?
Greater than 6 cm
Describe how to perform the cover/uncover test
Cover the patient’s eye with your hand and hold for at least three seconds. Uncover their eye and observe for any ocular malalignment or movement
What are positive findings during the cover/uncover test, and what are they indicative of?
Vertical skew - central lesion
Strabismus - ocular motor weakness or peripheral nerve pathology
Negative - typical for peripheral vestibular pathology
What is strabismus?
Eye movement due to ocular motor weakness of peripheral nerve pathology
What is exotropia?
Eye abduction during cover/uncover test
What is esotropia?
Eye adduction during cover/uncover test
What does the Gaze Evoked Nystagmus test tell us?
If the pathology is central or peripheral
Describe how to perform the Gaze Evoked Nystagmus test
Hold a piece of paper to the side of the patient’s face and tell them to keep their head straight, but try to look through the paper
What would a positive Gaze Evoked Nystagmus test look like?
UVH: nystagmus in the same direction but greater when looking toward the direction of the fast phase
Central: nystagmus changes direction
Describe how you assess VOR
Hold a pen in front of the the patient and have them fixate as they move their head left and right. Repeat with moving their head up and down
How fast should the patient move their head when testing VOR?
2 Hz
What is a positive finding when assessing VOR and what does it indicate?
Vertigo or saccades. Indicative of CN VIII pathology, central lesion beyond the nuclei, UVH, or BVH
Describe how to perform VOR Cancellation
Have the patient sit with their hands clasped and arms stretched out in front of them. Have them rotate their body and head while they maintain their gaze on the target
What is a positive finding for VOR Cancellation?
Corrective saccades or vertigo
What do you need to do before performing the HIT?
Assess cervical ROM
What does the HIT examine?
VOR bilaterally, can determine if it is a unilateral or bilateral hypofunction
Describe how to perform the HIT
Flex the patients head to 30, rotate their head in both directions at a moderate speed and then rapidly rotate the head from one side to midline while the patient tries to maintain their gaze
What is a positive finding on the HIT?
Corrective saccade: rapid eye movement back towards the target, but if there is a dysfunction, VOR will will not move the gaze as quickly as the head rotates so eyes move off the target
What does a positive HIT test indicate?
Bilateral - BVH
Unilateral - UVH
Negative bilaterally - Central
What does the Head Shaking Nystagmus Test examine?
VOR
Describe how to perform the Head Shaking Nystagmus Test
Have the patient close their eyes, flex their neck to 30 degrees, and rotate head for 20 repetitions at a speed of 2 Hz. Stop and have them open their eyes. Perform both horizontal and vertical
What is a positive Head Shaking Nystagmus Test?
Nystagmus for three or more beats. Fast pace will be toward the intact ear
What does a positive Head Shaking Nystagmus Test indicate?
Positive: unilateral peripheral lesion
Negative: BVH due to no imbalance of tonic firing rates
Vertical nystagmus: central lesion
Describe the Dynamic Visual Acuity Test
Have the patient 10 feet from a Snellen Chart and have them read the lowest line. Flex their head to 30 and have them rotate at 2 Hz, then read the lowest line again
What is a positive finding on the Dynamic Visual Acuity Test?
Cannot read three lines or more from their established baseline
What does a positive Dynamic Visual Acuity Test indicate?
Hypofunction
What is the purpose of the HINTS Exam?
Rule out posterior circulation stroke
What is the requirement in order to perform the HINTS Exam?
Patient must present with nystagmus
What are the three components of the HINTS Exam?
Heat Impulse Test
Nystagmus during lateral gaze
Test of Skew
If a patient is assessed with the HINTS exam and presents with a negative Head Impulse, bidirectional nystagmus, and vertical movement during the Test of Skew. What is a concern?
Stroke
If a patient is assessed with the HINTS exam and presents with a positive Head Impulse, unidirectional nystagmus, and negative Test of Skew. What is a concern?
Peripheral concern
Which is a more sensitive test within the first 48 hours of a stroke, HINTS or MRI?
HINTS Exam
How do you test for cervicogenic dizziness?
Have the patient sit in a chair with either wheels or no armrests and have them look at a fixed point in front of them. Have them keep their head straight and turn their body to the side
What is a positive test for cervicogenic dizziness?
Vertigo, paresthesia, pain due to tension on the posterior column
Describe the Caloric Test
Warm or cold water is placed in the ear canal and eyes are observed
What direction would you expect nystagmus during the Caloric Test with cold water?
Away from the ear that the water was inserted into
What direction would you expect nystagmus during the Caloric Test with warm water?
Towards the ear that the water was inserted into
What SCC is being examined with the Caloric Test?
Horizontal canal
Describe the Vestibular Rehabilitation Benefit Questionnaire (VRBQ)
22 item questionnaire that was developed to identify the benefit of vestibular rehab
What categories are assessed with the Vestibular Rehabilitation Benefit Questionnaire (VRBQ)?
Dizziness, anxiety, motion-provoked dizziness, quality of life
Describe the methods of the Motion Sensitivity Quotient
Patient is placed in different position and symptoms are rated in terms of intensity and duration
What vestibular diagnosis is the Motion Sensitivity Quotient a good outcome measure for?
Central
Describe the Dizziness Handicap Inventory (DHI)
Self-report measure of an individual’s perception of dysequilibrium and impact on activity
What categories are assessed in the Dizziness Handicap Inventory (DHI)?
Functional, emotional, physical
Deficits in which trials during the CTSIB indicates vestibular dysfunction?
5 and 6
How would a patient with UVH initially present during the DGI or FGA?
Wide base of support, slow, limited trunk rotation
How would a patient with UVH present during the DGI and FGA after two weeks?
Normal
How would a patient with BVH initially present during the DGI or FGA?
Wide base of support, slow, limited trunk rotation
How would a patient with BVH present during the DGI and FGA after two weeks?
Progression to mild impairments, but not back to normal
How would a patient with Central Vestibular Pathology present during the DGI or FGA?
Ataxia, possibly veer toward more affected side
