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PHTY2230 Prac Exam (Balance and Vestib) > L14: Pathologies of the peripheral vestibular system, assessment practises for differential diagnosis > Flashcards

L14: Pathologies of the peripheral vestibular system, assessment practises for differential diagnosis Flashcards

1
Q

What are 3 key symptoms to ‘listen’ for or ask about to differentiate pathologies?

A

Can use closed questions here:

  1. Dizziness
  2. Type
  3. Duration (eg. can have multiples of dizziness V1 and V2)
  4. Associated auditory symptoms
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2
Q

_____ is the 2nd most common cause of vertigo.

A

Vestibular Neuritis

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3
Q

What is vestibular neuritis?

A

Acute inflammation of the vestibular nerve (CN VIII)

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4
Q

What often precedes vestibular neuritis?

A

a viral infection possibly the herpes virus

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5
Q

What is the superior division of the vestibular nerve?

A

Utricle and anterior/superior and horizontal canals

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6
Q

What is the inferior division of the vestibular nerve?

A

Saccule and posterior / inferior canal

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7
Q

What is the type of dizziness in vestibular neuronitis during the acute phase?

A

acute onset of prolonged rotary vertigo

Acute: spinning and can’t make it stop

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8
Q

What is the duration of vestibular neuronitis during the acute phase?

A

>1 but <4 days

At least a day but gone by 4 days

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9
Q

What are the provoking positions in vestibular neuronitis during the acute phase?

A

exacerbated by head movement… but present continuously (acute phase‐ has baseline level of symptoms)

Trying to activate vestibular system

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10
Q

What are the auditory symptoms in vestibular neuronitis during the acute phase?

A

no hearing loss; tinnitus; aural fullness (unless only inferior division – hearing loss)

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11
Q

What are the associated symptoms in vestibular neuronitis during the acute phase?

A

postural imbalance / nausea

Trouble walking but able to use limbs (eg. to crawl to bathroom to vomit)

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12
Q

What are the visual observations in vestibular neuronitis during the acute phase?

A

Nystagmus ‐ horizontal‐rotary nystagmus beating away from affected ear (may not be felt or called jumpy eyes by the patient)… more detail in objective assessment.

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13
Q

Which way does the nystagmus beat in vestibular neuronitis during the acute phase?

A

away from affected ear

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14
Q

What is Alexander’s Law?

A

individuals with nystagmus, the amplitude of the nystagmus increases when the eye moves in the direction of the fast phase (saccade). It is manifested during spontaneous nystagmus in a patient with a vestibular lesion.

Eg. beating to L and then look to the L you would get more beating than if you looked to the R

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15
Q

What is the type of dizziness in vestibular neuronitis after the acute phase?

A

‐ giddiness but will be symptom free at rest

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16
Q

What is the duration of vestibular neuronitis after the acute phase?

A

constant… as recovers / intermittent

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17
Q

What are the provoking positions/movements in vestibular neuronitis after the acute phase?

A

head movements

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18
Q

What are the auditory symptoms in vestibular neuronitis after the acute phase?

A

‐ ISQ to original symptoms

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19
Q

What are the associated symptoms in vestibular neuronitis after the acute phase?

A

postural imbalance / nausea / fatigue / jumpy vision – blurred with movement

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20
Q

Do you see a nystagmus in vestibular neuronitis after the acute phase?

A

May or may not see an ongoing horizontal nystagmus

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21
Q

What is vestibular labyrinthitis?

A

Presentation is identical to neuritis however with the additional symptom of hearing loss (lesion site = labyrinth)

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22
Q

How does vestibular labyrinthitis differ from vestibular neuronitis?

A

Presentation is identical to neuritis however with the additional symptom of hearing loss (lesion site = labyrinth) Sudden hearing loss (even if its recovered)

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23
Q

Where is the lesion in vestibular labyrinthitis?

A

Labyrinth

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24
Q

What is Meniere’s Disease and Endolymphatic Hydrops?

A
  • Disorder of inner ear function
  • Two variants
    • vestibular
    • cochlear
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25
Q

When are the onset of Meniere’s Disease and Endolymphatic Hydrops?

A

Usually has onset in the 4th – 6th decades

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26
Q

Meniere’s Disease and Endolymphatic Hydrops up to 25% ______ (unilateral/bilateral)

A

bilateral

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27
Q

What happens when there is an increase in fluid?

A

Increase of fluid at the perilymph –> over loads –> presses the hair cells (sac is not draining properly –> goes away)

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28
Q

What is the type of dizziness in Meniere’s Disease during the acute phase?

A

acute onset of prolonged rotary vertigo

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29
Q

What is the duration in Meniere’s Disease during the acute phase?

A

‐ minutes to hours <1 day

Eg. 45 mins

30
Q

What are provoking positions in Meniere’s Disease during the acute phase?

A

exacerbated by head movement… but present continuously (acute phase)

31
Q

What are auditory symptoms in Meniere’s Disease during the acute phase?

A

hearing loss +/ or aural fullness, tinnitus (low pitch) (UNILATERAL) Pressure fill (can hear fluid in the ear)

32
Q

What are associated symptoms in Meniere’s Disease during the acute phase?

A

postural imbalance / nausea / directional propulsion

33
Q

What are visual observations in Meniere’s Disease during the acute phase?

A

horizontal‐rotary nystagmus beating towards the affected ear (may not be felt or called jumpy eyes by the patient)… more detail in objective assessment

34
Q

Why is there a horizontal‐rotary nystagmus beating towards the affected ear in Meniere’s Disease?

A
  • Fluid is pushing on hair cells –> activating them –> Cause microdamage –> goes away 24 hrs later
  • Nystagmus –> other side (other side has become less activated(
  • Will look like neuritis but has hearing loss and goes away quickly
35
Q

What is the type of dizziness in Meniere’s Disease during the acute phase?

A

giddiness

36
Q

What is the duration in Meniere’s Disease during the acute phase?

A

constant / intermittent

37
Q

What are provoking positions in Meniere’s Disease during the acute phase?

A

head movements / busy environments/ visual stimulation

38
Q

What are auditory symptoms in Meniere’s Disease during the acute phase?

A

ISQ or return to normal – each progressive attack often not return to N

39
Q

What are associated symptoms in Meniere’s Disease during the acute phase?

A

postural imbalance / nausea / fatigue / jumpy vision – blurred with movement

40
Q

What are visual observations in Meniere’s Disease during the acute phase?

A

horizontal‐rotary nystagmus beating away from the affected ear (may not be felt or called jumpy eyes by the patient)… more detail in objective assessment Follow Alexander’s Law

41
Q

Which way does the nystagmus beat in Meniere’s Disease during the acute phase?

A

horizontal‐rotary nystagmus beating away from the affected ear (may not be felt or called jumpy eyes by the patient)… more detail in objective assessment Follow Alexander’s Law

42
Q

What are 4 characteristics of Perilymphatic Fistula?

A
  1. Abnormal opening between the air‐filled middle ear and the fluid‐filled inner ear (Taking away a bony structure)
  2. Usually occurs at the round and oval windows of the middle ear
  3. Usually has history of head trauma, barotrauma, surgery, penetrating injury or vigorous straining (labour)
  4. Patient often reports a “pop” in the ear during the precipitating event
43
Q

What is the most common form of fistula?

A

Semicircular Canal Dehiscence

44
Q

What is a Semicircular Canal Dehiscence?

A

Dehiscence of the superior semicircular canal • Loss of bone over the roof of the superior canal • Worn down with age and or postnatal bone development

45
Q

How do you diagnose Semicircular Canal Dehiscence?

A

Diagnosis very difficult usually a diagnosis of exclusion and subjectiveness.

46
Q

What is the type of dizziness in Perilymphatic Fistula/SCD?

A

vertigo – but not always

47
Q

What is the duration in Perilymphatic Fistula/SCD?

A

constant / intermittent

48
Q

What are provoking positions/movement in Perilymphatic Fistula/SCD?

A

‐head movements / busy environments / visual stimulation / noisy environments (tullios phenomenon / pressure inducing postures‐ actions (Hennebert’s sign)

49
Q

What are auditory symptoms in Perilymphatic Fistula/SCD?

A

hearing loss +/-

50
Q

What are associated symptoms in Perilymphatic Fistula/SCD?

A

postural imbalance / nausea / fatigue / jumpy vision – blurred with movement

51
Q

What are visual observations in Perilymphatic Fistula/SCD?

A

horizontal‐rotary nystagmus beating toward affected ear (may not be felt or called jumpy eyes by the patient)… more detail in objective assessment

52
Q

What are 4 symptoms that patients complain of in Perilymphatic Fistula / SCD?

A
  1. Everytime I cough or sneeze —> get a wave of dizziness
  2. Can hear the blood flow, can hear eyes move
  3. Cant go to club (sound waves going in) –> get dizzy
  4. Very noisy, loud hearing Loss the bony causing an opening
53
Q

What is Vestibular Schwannoma / Acoustic Neuroma (AN)?

A

Non‐malignant tumour on the vestibular portion of the VIIIth (8th) CN

54
Q

What is the third most common intracranial tumours in adult?

A

Vestibular Schwannoma / Acoustic Neuroma (AN)

55
Q

What is the size of Vestibular Schwannoma / Acoustic Neuroma (AN)?

A

range up to 4cm

  • small < 1.5cm
  • medium 1.5 – 3cm
  • large > 3cm
56
Q

Which diagnostic modalities are used for Vestibular Schwannoma / Acoustic Neuroma (AN)?

A

CT scans = useless (unable to see the layers of bone) MRI = helpful

57
Q

What action must be taken for any unilateral hearing loss?

A

Requires medical emergency

58
Q

What is the type of dizziness in Acoustic Neuroma?

A

giddiness / rocking / directional propulsion

59
Q

What is the duration in Acoustic Neuroma?

A

constant / intermittent… depends on growth rate

60
Q

What are provoking positions/movement in Acoustic Neuroma?

A

head movements / busy environments / visual stimulation

61
Q

What are auditory symptoms in Acoustic Neuroma?

A

hearing loss UNILATERAL (usually first sign) / tinnitus

62
Q

What are associated symptoms in Acoustic Neuroma?

A

postural imbalance / nausea / fatigue / jumpy vision blurred with movement/ head aches / facial weakness / facial numbness

63
Q

What are visual observations in Acoustic Neuroma?

A

No nystagmus unless acute and poorly adapted

64
Q

Why is it rare to describe spinning in an acoustic neuroma?

A

Rare to describe spinning as tumour is slow growing – may get spinning after resection

65
Q

What are 4 common causes of Bilateral vestibular dysfunction?

A
  1. Ototoxic (11‐17%) – Gentamicin toxicity
  2. Menieres Disease (2‐13%)
  3. Infection (6‐11%) – Bilateral sequential vestibular neuritis
    • Rarely complete due to neuroanatomy of the superior vestibular nerve – Meningitis
    • Often associated with profound hearing loss
  4. Unknown (21‐50%)
    • Age related not fully understood.
66
Q

In age-related changes, if you slowly lose hearing loss what happens?

A

• If slowly losing hearing loss –> vestibular system will decline as well • Older imbalanced individual –> decay –> Determine if can try to recallibrate all the systems ○ Bifocals –> hard to callibrate ○ Want to hold on ○ Very imbalanced ○ Billateral hearing loss ○ Ringing in their ears Unilateral –> possible spinning

67
Q

What are 4 presenting signs and symptoms of Bilateral vestibular dysfunction (BVL)?

A
  1. Dependent on etiology
    • need to consider all pathologies to provide a diagnosis of exclusion
    • (wastebasket diagnosis).
  2. If bilateral onset in time
    • Balance and oscillopsia / jumpy vision
    • Sense of dysequilibrium
    • +/‐ Bilateral hearing loss
    • Bilateral tinnitus
  3. Asymmetrical onset
    • C/o dizziness (true spinning) due to the imbalance between sides
    • Balance and oscillopsia
    • Sense of dysequilibrium
    • +/‐ Unilateral hearing loss
    • Unilateral tinnitus
  4. Pathology may be progressive… may not be symmetrical hence variable symptoms
68
Q

What is the prevalence of geriatric dizziness?

A
  • US and UK reported rates of dizziness 28 – 34% over 60 years c/o dizziness and balance problems
  • Recent study demonstrates nicely the prevalence of vestibular dysfunction as individuals age with 49.4%, 68.7% and 84.8% or people at ages 60–69, 70–79 and 80 and over, respectively.
69
Q

What is vestibular system dysfunction a risk for?

A

Risk for falls

70
Q

What are 6 age-related changes to the vestibular system in bilateral vestibular loss?

A
  1. Hearing loss and sac cular dysfunction
  2. Associated with noise screen for presbycusis.
  3. Increased risk of BPPV – reduction in reabsorption of cristae or increased loss
  4. Diabetes – hair cell loss disequilibrium.
  5. Decline in semi‐circular canals and otoliths in combination with ageing.
  6. Reduction in Vestibular Ocular
    • reflex (VOR) gain at higher
    • velocities
  7. Reduced ability to adapt the gain of the vestibular system.
71
Q

What are 9 tests in the oculomotor evaluation?

A
  1. Spontaneous nystagmus
  2. Gaze evoked nystagmus
  3. Skew eye deviation (acute only)
  4. Smooth pursuit
  5. Saccades
  6. VOR Cancellation
  7. VOR
  8. Head Impulse Test (head thrust test)
  9. Head Shaking nystagmus Vision denied 1‐2‐8(Shimp test) – pressure induced
72
Q

What are 6 tests for oculomotor evaluation to check for neuro-central network (Related to the brain)?

A
  1. Spontaneous nystagmus
  2. Gaze evoked nystagmus
  3. Skew eye deviation (acute only)
  4. Smooth pursuit
  5. Saccades
  6. VOR Cancellation

PHTY2230 Prac Exam (Balance and Vestib) (12 decks)

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