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Clinical Conditions II > Final - Vestibular Disorders > Flashcards

Final - Vestibular Disorders Flashcards

1
Q

Dizziness

A

The sensation of disturbed or impaired spatial orientation without a false or distorted sense of motion (lightheadedness, nonspecific dizziness, not vertigo)

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2
Q

Presyncope

A

The sensation of impending loss of consciousness

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3
Q

Syncope

A

Transient loss of consciousness due to transient global cerebral hypo perfusion characterized by rapid onset, short duration, and spontaneous complete recovery

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4
Q

Vertigo

A

Sensation of self-motion when no self-motion is occurring or the sensation of distorted self-motion during an otherwise normal head movement

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5
Q

Unsteadiness

A

The feeling of being unstable while seated, standing, or walking without a particular directional preference (disequilibrium or imbalance)

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6
Q

How are vestibular disorders diagnosed?

A
  1. history
  2. physical exam
  3. diagnostic testing if necessary
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7
Q

what are the types of vestibular disorders?

A

Unilateral vs Bilateral

Peripheral vs Central

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8
Q

Central Vestibular Disorder

A

In the cerebellum

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9
Q

TiTrATE

A

Triage: Identify dangerous causes (abnormal vital signs, altered mental status)
Timing: Determine the dizziness attack pattern (episodic, acute, chronic)
Triggers: Seek obvious triggers or exposures
Targeted Exam: Vestibular Exam
Testing: Further diagnostic testing when appropriate

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10
Q

Timing

A

onset, duration, and evolution of dizziness

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11
Q

Episodic timing

A

intermittent dizziness lasting seconds, minutes, or hours

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12
Q

Acute Timing

A

acute, persistent dizziness lasting days to weeks, sometimes with lingering sequelae
** Temporal evolution at onset and in first week most important

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13
Q

Chronic Timing

A

Lasting longer than 3-6 months

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14
Q

Positional Triggers

A

Head changes

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15
Q

Exposures

A

Head/neck trauma
Barotrauma
Toxin exposure
Medications

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16
Q

Benign Positional Vertigo

A

Seconds to few minutes

triggered by head position changes

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17
Q

Vestibular neuritis

A

hours to 2-3 days

spontaneous trigger

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18
Q

Meniere’s Disease

A

Minutes to 24 hours

Spontaneous triggers

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19
Q

Vestibular Migraine

A

Seconds to Weeks

Head changes/ spontaneous

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20
Q

Targeted Exam - Positional Testing

A

Supine Roll Test

Dix-Hallpike Test

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21
Q

4 key acute categories

A
  1. episodic vestibular syndromes: triggered or spontaneous

2. acute vestibular syndromes: post-exposure or spontaneous

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22
Q

BPPV

A
  • Timing: episodic lasting seconds
  • Triggers: rolling onto side, moving from sitting to lying, looking upward, “swimming sensation”
  • Targeted Exam: Dix-Hallpike Evaluation
  • Treatment: Employ maneuver/canalith repositioning procedure
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23
Q

BPPV Pathophysiology

A
  1. Cupulolithiasis: debris attached to cupula
  2. Canalithiasis: Debris within long arm (delay)
  3. Vestibulithiasis: debris within short arm (type 2)
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24
Q

BPV causes

A
  • Idiopathic 70-80%
  • Head Injury
  • Vascular
  • Viral Infection
  • Meniere’s Disease
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25
Q

BPV Diagnosis

A
  • History

- Positional Testing: Dix-Hallpike Evaluation or Supine Roll Test

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26
Q

Unilateral Peripheral Vestibular Deficit

A
  1. Timing: acute onset, persistent, continuous dizziness (hours to weeks)
  2. Triggers: Spontaneous
  3. Targeted History: Nausea/vomiting, gait instability, head-motion intolerance
  4. targeted exam: HINTS Evaluation (head impulse nystagmus test of skew)
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27
Q

Causes of Unilateral Peripheral Vestibular Deficit

A
  • Vestibular Neuritis/Neuronitis
  • Labyrinthitis
  • Sudden Sensorineural Hearing Loss
  • Early Meniere’s Disease
  • Fractured Temporal Bone
  • Stroke
  • Head Trauma
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28
Q

Vestibular Neuritis Cause

A

Viral Infection of CN VIII

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29
Q

Vestibular Neuritis Symptoms

A
  • Severe vertigo (hours to days)
  • nausea/vomiting
  • NO HEARING LOSS**
30
Q

Vestibular Neuritis Treatment

A
  • Vestibular Suppressants/ Anti-Emetics/ Steroids

- Vestibular Rehabiliation

31
Q

Labyrinthitis: Viral or Bacterial Infection of Inner Ear Symptoms

A

Sudden onset of:

  • severe vertigo (hours to days)
  • nausea/vomiting
  • *unilateral profound sensorineural hearing loss
32
Q

Labyrinthitis: Viral or Bacterial Infection of Inner Ear Treatment

A
  • Vestibular Suppressants/ Anti-Emetics/ Steroids

- Vestibular Rehabiliation

33
Q

Unilateral Peripheral Vestibular Deficit: Head Injury TiTrATE

A
  • Timing: Acute
  • Trigger: Trauma
  • Targeted History: blunt head trauma, whiplash history
  • Targeted Exam: HINTS evaluation, Head Evaluation, Radiographic EvaluationC
34
Q

Common in patients with head injury

A

Vestibular Hypofunction

  • Without skill fracture: 28%
  • with skull fracture (not temporal bone): 50%
  • with skill fracture of temporal bone: 87-100%
35
Q

Other causes of Unilateral Vestibular Hypofunction

A
  • labyrinthectomy (Meniere’s Disease)
  • Vestibular Neurectomy (Meniere’s Disease)
  • Semicircular Canal Plugging (BPV, SSCD)
  • Acoustic Neuroma Resection
36
Q

What is an acoustic neuroma

A

proliferation of the sheath producing Schwann cells of CN VIII

37
Q

Symptoms of acoustic neuroma

A
  • unilateral hearing loss
  • unilateral tinnitus
  • unsteadiness/ vertigo
38
Q

acoustic neuroma treatment

A
  • observation
  • microsurgery
  • radiosurgery
39
Q

Symptoms of Unilateral Vestibular Deficit

A
  • increased tone in the extensor muscles of contralateral side: inadequate postural response
  • Oscillopsia (objects appear to move when they are still)
40
Q

Signs of Unilateral Vestibular Deficit

A
  • Unidirectional horizontal spontaneous nystagmus –> fast phase toward healthy ear
  • Acute phase: up to 5 days after lesion (nystagmus seen with fixation)
  • Chronic phase: >5 days and up to 8 years (nystagmus suppressed by active fixation)
41
Q

Tests of integrity of VOR

A
  • Head Impulse Test

- Dynamic Visual Acuity Test/Dynamic Illegible E Test

42
Q

Test for vestibular tone imbalance

A

Spontaneous nystagmus/ head shaking nystagmus

43
Q

Postural imbalance Testing

A
  • Modified Clinical Test of Sensory Interaction and Balance

- Dynamic Gait Index

44
Q

Unilateral Peripheral Deficit Testing- Bithermal Caloric Testing

A
  • Test of lateral SCC only
  • Cold/warm air or water
  • unilateral weakness
  • > 25% difference between sides
  • measure of movements 0.003 Hz
45
Q

Unilateral Peripheral Deficit: Testing - Video Head Impulse Test

A
  • test of lateral and vertical SCCs

- measure movements 5-6 Hz

46
Q

Vestibular Testing: cVEMP

A

saccule and inferior vestibular nerve

47
Q

vestibular testing: oVEMP

A

utricle and superior vestibular nerve

48
Q

Rotary Chair Testing

A
  • head tiled forward 30 degrees: lateral canal in horizontal position
  • Uses: check for compensation from unilateral vestibular loss or to check for bilateral vestibular weakness
49
Q

Does platform posturography tell you where the lesion is?

A

no

only tells you the vestibular loss pattern

50
Q

Vestibular Testing Summary

A
  • Caloric testing: lateral semicircular canal and sup vestibular nerve
  • vHIT: all canals
  • cVEMP: saccular function –> inf vestibular nerve
  • oVEMP: utricle function –> sup vestibular nerve
  • Rotary chair: lateral semicircular canal
  • platform posturography: objective eval of vest system
51
Q

Unilateral Vestibular Deficit: Goals of Treatment

A
  • increase gain of central vestibular system to improve function of VOR
  • improve postural control
52
Q

Bilateral Vestibular Deficit: Ototoxic Medications

A
  • Aminoglycosides
  • Neoplastics
  • Loop Diuretics
  • Quinine
  • IV Erythromycin
53
Q

Bilareal Vestibular Deficit: SxS

A
  • Vertigo: if none, symmetric loss; if yes, asymmetric loss
  • Nystagmus: if none, symmetric loss; if yes, asymmetric loss
  • Oscillopsia
  • Postural imbalance
54
Q

Bilateral Vestibular Deficit: Bedside Testing

A
  • Gain of VOR: dynamic visual acuity test
  • Postural Imbalance: Modified Clinical Test of Sensory Interaction and Balance, Dynamic Gait Index or Functional Gait Assessment
55
Q

Bilateral Vestibular Deficit: Treatment

A
  • Stop ototoxic medication
  • stop vestibular suppressants
  • vestibular rehabilitation
56
Q

Vestibular Rehabilitation Goals for Bilateral Vestibular Deficit

A
  • Increase gain of central vestibular system
  • Improve static & dynamic postural control in many sensory environments
  • Strategies to facilitate compensation: teach substitution and avoidance strategies
57
Q

Do fluctuation vestibular deficits response to vestibular rehabilitation?

A

no

58
Q

Fluctuating Vestibular Conditions: Meniere’s Disease

A
  1. episodic, spontaneous
  2. sensorineural hearing loss
  3. ? tinnitus
  4. ? aural fullness
59
Q

Fluctuating Vestibular Conditions: Meniere’s Disease Rx

A
  • Acute vertigo –> treat symptomatically
  • Long term management –> low sodium, diuretics, betahistine
  • Intratympanic Steroids
  • Surgical Management: endolymphatic shunt, vestibular nerve section, labyrinthectomy
60
Q

Fluctuating Vestibular Conditions: Perilymphatic Fistula

A
  • Timing: Acute vestibular syndrome
  • Trigger: Traumatic
  • Targeted History/Exam: Barotrauma, blast injury, weight lifting, spontaneous
61
Q

Fluctuating Vestibular Conditions: Perilymphatic Fistula Symptoms

A
  • Hearing Loss
  • Tinnitus
  • Vertigo
  • Disequilibrium
  • Worse w/ coughing, nose blowing, etc
62
Q

Fluctuating Vestibular Conditions: Perilymphatic Fistula Rx

A
  • Bedrest
  • Diuretic: acetazolamide
  • Surgical Exploration/ Repair
63
Q

Fluctuating Vestibular Conditions: Superior Semicircular Canal Dehiscence Symptoms

A
  • Dizziness/ chronic disequilibrium (sound or pressure induced)
  • pulse- synchronous oscillopsia
  • hyperacusis
  • low-frequency conductive hearing loss
  • pulsatile tinnitus
  • brain fog/fatigue
  • osculophonia (hearing eyes move)
64
Q

Fluctuating Vestibular Conditions: Superior Semicircular Canal Dehiscence Diagnosis

A

cVEMP

CT Temporal Bones

65
Q

Fluctuating Vestibular Conditions: Superior Semicircular Canal Dehiscence Treatment

A
  • Tympanostomy tube

- Surgical plugging of canal

66
Q

Vascular Lesions to the Central Vestibular System TiTrATE

A
  • Timing: Acute onset continuous lasting days to weeks
  • Triggers: Spontaneous
  • Targeted Hx/Exam:
    Continuous dizziness/vertigo
    head motion intolerance
    gait instability/nystagmus
    HINTS exam
    MRI brain
67
Q

Head Impulse Nystagmus Test of Skew (HINTS)

A

3 step bedside examination for acute vestibular syndrome:

  • head impulse test
  • nystagmus
  • test of skew
68
Q

What’s does the HINTS test do?

A

differentiates between peripheral and central dysfunction

69
Q

Stroke is suspected if any one of the three following exist: (HINTS)

A
  • normal head impulse test
  • direction changes nystagmus
  • skew deviation (100% desensitize and 96% specific)
70
Q

Causes of lesions of the central vestibular system

A
  • vascular: vertebro-basilar
  • head trauma
  • brain tumors
  • cerebelar degeneration
71
Q

Lesions of the Central Vestibular System: Nystagmus

A
  • Vertical (up or down beating)
  • Sustained gaze evoked nystagmus: inability to maintain stable conjugate eye deviation away from the primary position
  • Central positional nystagmus: may mimic benign positional nystagmus
72
Q

Exam findings of central vestibular system lesion

A
  • gait/ limb ataxia
  • ocular tilt
  • lateropulsion
  • dysmetria

Clinical Conditions II (11 decks)

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