Lecture 5: Diziness And Disequilibrium Flashcards
What proportion of elderly people experience Dizziness/Balance? And what age?
1:5 people experience dizziness ≥ 65 years of age
What percentage of people ≥65 years of age have experience some form of dizziness?
80%
What percentage of adults experience some form of vestibular dysfunction? What age?
15-35% of adults experience vestibular dysfunction.
≥40 years of age
(Blank) accounts for 1/3 of all dizziness and vertigo reported to health care providers
Vestibular dysfunction
This is the most common vestibular disorder in older people
Benign Proxysmal Positional Vertigo (BPPV
What is the general flow of information from the Semicircular canals to the cerebellum?
=>Semicircular canals Stimulated
==>Vestibular Ganglion
===>Vestibular root
====>Vestibulochochlear N CN VIII
=====> Inf. Lat. Med. Sup. Vestibular nucleus
=====> Direct fibers to cerebellum to Flocculus of cerebellum
What are the two portions for vestibular information gathering in the ear?
Ampulla
Macula
Semicircular canals
This portion of the inner ear contains the cupola, cilia, hair cells, crista amullaris, and axons to vestibular ganglion.
Ampulla
This part of the inner ear contains the otoliths, gelatinous layer, and hair cells
Macula
the Oculomotor nucleus is located with what portion of the brain stem?
Midbrain
The abducens nucleus is located in what portion of the brain stem?
Pons
The medial vestibular nucleus is located in what portion of the brain stem?
Rostral Medulla
The Scarpa’s ganglion is located in what portion of the brain stem?
Rostral Medulla
Symtptoms of dizziness can be (Blank) and (Blank) timewise.
- Sudden
2. Insidious onset
What are the temporal features associated with dizziness?
- Episodic
2. Persistent
If dizziness lasts seconds, minutes, or hours, what is it classified as?
Episodic
If dizziness lasts days or weeks; continuous, it is considered?
Persistent
Dizziness can be associated with positional changes related to (blank) and (blank)
- Body Posture
2. Head positions
This is the sensation of movement in the absence of stimuli: spinning, rocking, and tilting.
Vertigo
This is a symptom of unsteadiness or imbalance, occurring mainly when standing up or walking and better when sitting or lying down.
Disequilibrium
This symptom is classified as presyncope, light-headed Ess., foggy head, spatial disorientation
Dizziness Hypotension
For patients with vertigo, therapists should ask the following … (4)
- Episodic duration of spell
- Change with head positions
- Associated nausea and vomiting
- Constant associated disequilibrium
For patients with Disequilibrium, PT’s should ask about… (3)
- Associated neurologic symptoms
- Difficulty ambulating in the dark
- Other types of vestibular symptoms
for patients with dizziness hypotension, PT’s should ask about …
- Associated heart disease
- Postural symptoms that occur upon standing
- Palpitations
- Medication use
- Anxiety
- Hyperventilation
What are the associated symptoms related to dizziness?
- tinnitus
- Nausea/Vomiting
- Hearing Loss
- visual Changes
- Aural Fullness
- Photophobia
- Photophobia
- 4 D’s Diploplia, Dysarthria, Dysphagia, Dysmetria
What are the special tests to be performed with a patient who presents with dizziness? (3)
- MRI
- CT
- Audiometric Examination
This special test looks for brain and internal auditory canals with or without Gadolinium
-Identification of infarction, tumor
MRI
This special test looks for temporal bones, brain, and internal auditory canals
It assists in identification of hemorrhage, infarction, or tumor
CT Scan
This special test looks for distinction between conductive or sensorineural loss
-Word distinction measure of patient’s ability to understand speech
Audiometric Examination
These tests are used to asses the inner ear responses (2)
- Electronystagmography (ENG)
2. Videonystagmography (VNG)
What are the different sub-types of tests for assessment of inner ear responses?
Vestibular Evoked Myogenic Potentials (VEMP)
- Spontaneous Eye movements
- Position Testing
- Visual Tracking
- Vestibular Testing (Caloric and Rotary chair testing)
This is a reflexive, rhythmic oscillation of the eyes. Consists of Slow and Fast beats
Nystagmus
How to you determine the direction of Nystagmus?
The fast component is in the direction of the ear with increased neural activity
When is Nystagmus considered normal?
When you take someone to their visual end range
Abnormal Nystagmus is seen with )Blank) and (Blank) vestibular dysfunction.
- Central Vestibular Dysfunction
2. Peripheral Vestibular Dysfunction
What direction does the nystagmus beat in?
The fast beating side, indicating the side with intact neural activity usually
What are the 2 generalized distinctions for Nystagmus?
- Peripheral vestibular Nystagmus
2. Central Vestibular Nystagmus
This type of Nystagmus is direction fixed nystagmus (Horizontal)
A. Peripheral Vestibular
B. Central Vestibular
C. Both
A. Peripheral Vestibular
This type of Nystagmus is direction changing nystagmus with changes in gaze
A. Peripheral Vestibular
B. Central Vestibular
C. Both
B. Central Vestibular Nystagmus
this type of nystagmus with visual fixation may decrease over time.
A. Peripheral Vestibular
B. Central Vestibular
C. Both
A. Peripheral Vestibular Nystagmus
This type of Nystagmus is direction changing nystagmus, while remaining in one position
A. Peripheral Vestibular
B. Central Vestibular
C. Both
B. Central Vestibular Nystagmus
This type of Nystagmus usually increases with visual fixation
A. Peripheral Vestibular
B. Central Vestibular
C. Both
B. Central Vestibular
This type of Nystagmus is Pure Vertical or Pure Torsional
A. Peripheral Vestibular
B. Central Vestibular
C. Both
B. Central Vestibular
This type of nystagmus is intense without subjective complains of vertigo.
A. Peripheral Vestibular
B. Central Vestibular
C. Both
B. Central Vestibular
This type of Nystagmus is Exaggerated when looking in direction of fast beat (Follows Alexander’s Law)
A. Peripheral Vestibular
B. Central Vestibular
C. Both
A. Peripheral Vestibular Nystagmus
This type of Nystagmus is characteristic mixed pattern of torsion with vertically, e.g. Right torsion, up beating (follows Flouren’s Law)
A. Peripheral Vestibular
B. Central Vestibular
C. Both
A. Peripheral Vestibular Nystagmus
What are the 5 types of Peripheral Vestibular Disorders?
- BPPV
- Vestibular Neuritis/Labrynthitis
- Ototoxicity
- Meniere’s Disease
- Acoustic Neuroma
What are the 6 types of Central Vestibular Disorders?
- TBI/Concussion
- TIA/Stroke
- Cerebellar Disorders
- Tumors
- MS
- Migraines
What is the most common cause of Vertigo?
BPPV
What is true of the likelihood of BPPV with increased Age?
Increases with Age
Who is more likely to experience BPPV? Men or women?
Women > Men
Benign paroxysmal Positional Vertigo is related to what structure in the inner ear?
The semicircular canals
What happens to a patient that they develop BPPV?
Otoconia become displaced and move through the semi-circular canals.
What is the etiology and pathogenesis of BPPV? (5)
- Idiopathic
- Post-traumatic
- Viral Neurolabrynthitis
- Vertebrobasilar Ischemia
- Meniere’s
What are the 3 tests that are related to diagnosing BPPV?
Positional Testing
1. Did Hallpike: Anterior and Posterior Canals
- Roll Test: Horizontal/Lateral Canals
- Fatigues with Repeated Testing
What are the 2 different forms of BPPV?
- Canalithiasis
2. Cupulothiasis
What are the classic signs and symptoms associated with BPPV?
Vertigo + Nystagmus with Positional testing
If vertigo + Nystagmus with positional testing lasts less than 60 seconds, it is considered?
BPPV: Canalithiasis
If Vertigo + Nystagmus with positional testing lasts greater than 60 seconds, it is …
BPPV: Cupulolithiasis
What is the typical timeline of BPPV?
- Sudden onset of Vertigo + Nystagmus with positional changes
- Last Seconds (Possibly minutes)
- Episodic Vertigo + Nystagmus with positional changes
What is the PT treatment for BPPV?
Repositioning Maneuvers
What is the prognosis of BPPV?
Excellent with PT
What is the incidence of Vestibular Neuritis/Labrynthitis and Unilateral vestibular hypofunction?
Age onset?
Mean age for men?
Mean age for women?
3.5 per 100,000
More prevalent in individuals 30-60 years old
Women in 40s
Men in 60s
This is when the Vestibulochochlear, facial, auditory, and cochlear nerve are possibly inflamed
Vestibular Neuritis: Inflammation of the nerves
This is when the Cochlea or semicircular canals are inflamed
Labrynthitis: Inflammation of the inner ear
Vestibular Neuritis, Labyrinthitis, and Unilateral Vestibular Hypofunction are probably caused by? (4)
- Viral Infection
- May be preceded by viral infection of the Upper Respiratory or GI tract - Autoimmune
- Vascular
- Bacterial
Vestibular Neuritis is inflammation to what tissue?
Cranial Nerve VIII: Vestibulocochlear
Labyrinthitis is closely related to …
Endolymph fluids
With Vestibular Neuritis and Labyrinthitis, damage occurs unilaterally resulting in…
Unilateral Vestibular Hypofunction (UVH)
With Vestibular Neuritis/Labyrinthitis Unilateral Vestibular Hypofunction, symptoms are typically exacerbated by …
Head movements due to inaccurate VOR
Why does Nystagmus occur?
There is a difference between the sensation the ears are getting
What is the typical timeline progression of Vestibular Neuritis/Layrinthitis Unilateral Vestibular Hypofunction?
- Sudden onset of vertigo. May experience nausea, vomiting, nystagmus
- Lasting 1-3 days
- After 3 days, decreased or no vertigo, but continued dizziness/Disequilibrium
- Symptoms improving, but may still be worse with quick head movements
What are the signs and symptoms associated with Vestibular Neuritis/Labyrinthitis Unilateral Vestibular Hypofunction?
Acute! (6)
- 1-3 Days of Vertigo
- Nausea/Vomiting
- Disequilibrium
- Nystagmus
- Changes in hearing (SNHL-sensory neural hearing loss)
- Evidence of Unilateral VOR dysfunction
What are the signs and symptoms associated with Vestibular Neuritis/Labyrinthitis Unilateral Vestibular Hypofunction?
After 3 days (5)
- Disequilibrium
- Continuous/Variable
- Better with no movement
- Worse with movement - Feels OFF
- Decreased concentration
- Changes in hearing (SNHL)
- Evidence of Unilateral VOR Dysfunction (+) HIT
For VEstibular Neuritis/Labyrinthitis Unilateral Vestibular Hypofunction, what are the key diagnostic studies to rule in/out disease?
VNG/ENG
These studies identify reduced unilateral response to caloric stimulation (Ipsilateral Hypo-responsiveness or non-responsiveness)
VNG/ENG
For PT’s what is the treatment plan for a patient who presents with Vestibular Neuritis/Labyrinthitis UVH? (3)
- Vestibular Suppressants Initially to help mange symptoms in acute phase (Meclizine)
- After acute symptoms, discontinue vestibular suppressants to optimize central compensation
- Vestibular Rehabilitation
What is the typical prognosis for a patient that presents with Vestibular Neuritis/Layrinthitis UVH?
Good to excellent with PT
BPPV is a central or Peripheral disorder?
Central
BPPV is a labyrinth or nerve disorder?
Labyrinth disorder
Vestibular Neuritis/Labyrinthitis UVH is a central or peripheral disorder?
Peripheral
Vestibular Neuritis/Labyrinthitis UVH is related to the labyrinth or nerve?
Vestibular Neuritis: CN 8
Labyrinthitis: Yes…!
Meniere’s Disease can be classified as
A. Unilateral Hypofunction
B. Bilateral Hypofunction
C. Both
C. Both Unilateral or Bilateral Dysfunction
What is the incidence of Meniere’s Disease Unilateral/Bilateral Hypofunction?
Men Vs. women
Age of Onset
Unilateral Vs. Bilateral
Men = Women
Onset 40-60 years of age
Bilateral involvement ranges between 33-50%
What is the pathogenesis of Meniere’s disease Unilateral/Bilateral Hypofunction? (4)
- Trauma
- Infection
- Immune-Mediated
- Genetic Pre-disposition
What is true of the etiology of Meniere’s disease Unilateral/Bilateral Hypofunction? (3)
- Malabsorption of Endolymph
- Increase pressure and volume cause abnormal firing of hair cells
- Episodic in nature lasting hours to days
- Initially full recovery after flares
- Overtime permanent damage to vestibular and cochlear organs
Describe the timeline for Meniere’s Disease Unilateral/bilateral Hypofunction (6)
- Sudden onset of vertigo, tinnitus, fullness, and hearing loss
- Lasting minutes to hours
- Resolution of symptoms
- Sudden onset of vertigo, tinnitus, fullness, and hearing loss
- Fluctuating, progressive in nature
- Eventful permanent hearing loss, Disequilibrium
What are the signs and symptoms associated with Meniere’s Disease Unilateral/Bilateral Hypofunction? (3)
- episodic Flares
- Motion Sensitivity
- Visual Disturbances
For Menerie’s Disease Unilateral/Bilateral Hypofunction, Under episodic flares, what can occur? (8)
- Vertigo >20min but < 24hours
- Fluctuating sensorineural hearing loss (Low frequency hearing loss, may lead to permanent loss)
- Ear Fullness
- tinnitus
- Disequilibrium
- Nausea
- Vomiting
- Anxiety
What are the key diagnostic tests for Meniere’s disease Unilateral/bilateral Hypofunction? (2)
- Audiogram
2. VNG/ENG calorics
What is the treatment for Meniere’s disease Unilateral/bilateral Hypofunction? (7)
- Diet (low sodium, high alcohol, high nicotine, high caffeine)
- diuretics
- Suppressive Medications (Acute phase-not as daily medication)
- Surgery (vestibular nerve section, Labyrinthectomy)
- Gentamicin Perfusion
- Psychological support
- Vestibular Rehabilitation (With permanent loss)
What is the prognosis of Meniere’s Disease Unilateral/bilateral Hypofunction?
Excellent control with Gentamicin/surgery
How long does it take for Meniere’s Disease Unilateral/bilateral Hypofunction?
May self-limit in 2-20 years
What components of the vestibular system can be effected to classify if as Central vestibular dysfunction?
Damage to the …
- Superior Vestibular nucleus
- Medial Vestibular Nucleus
- Lateral vestibular Nucleus
- Inferior Vestibular Nucleus
- Direct Fibers to the cerebellum
- Flocculus of Cerebellum
What are the 8 causes that could lead to Central Vestibular Dysfunction?
- Vestibular Migraine (Migraines associated with dizziness)
- Multiple Sclerosis
- TIA/Stroke (Transient Ischemic Attack)
- TBI/Concussion (Traumatic Brain Injury
- Vertebrobasilar Ischemia
- Cerebellar Disorders
- Tumors
- Drug Intoxication
What are the symptoms associated with Central Vestibular Dysfunction? (7)
- Disequilibrium
- Nausea
- Light headed
- Headache
- Falls
- Oscillopsia
- Occasionally vertigo
What are the signs of Central Vestibular Dysfunction? (9)
- Incoordination
- Ataxia
- Disequilibrium
- Abnormal Cnvergence
- Nystagmus
- Impaired VOR Cancellation
- Sacadic Smooth Pursuit
- Abnormal Saccades
- 4 (D’s)
- Diplopia
- Dysphagia
- Dysarthria
- Dysmetria
What are the non-vestibular causes of Dizziness? (9)
- Multifactorial Faller
- Orthostatic Hypotension
- Arrhythmias
- Diabetes
- Hypoglycemia
- Infection
- Medications
- Panic Attacks
- Anxiety
What is the etiology of BPPV (Peripheral and mechanical)?
Displaced Otoconia
What is the etiology of Unilateral Vestibular Hypofunction (Peripheral)? (3)
- Inflammation
- Infection
- Trauma
What is the etiology of Bilateral Vestibular Hypofunction (Peripheral)?
Metabolic
What is the etiology of Vestibular Nucleus and/or cerebellar Involvement (Central) (5)
- Vascular issues
- Degeneration
- Neoplastic (New and abnormal growth of tissue (cancer)
- Infection
- Trauma
What is the etiology of of Non-vestibular causes of dizziness and balance issues? (10)
- Multifactorial faller
- Orthostatic Hypotension
- Arrhythmias
- Diabetes
- Hypoglycemia
- Infection
- Medications
- Panic Attacks
- Anxiety
What are the signs and symptoms associated with BPPV (Peripheral or Mechanical) (2)
- Usually Short duration vertigo
2. Mixed Direction Nystagmus with changes in head position
What are the signs and symptoms associated with Unilateral Vestibular Hypofunction (Peripheral)
Acute?
Sub-Acute?
Acute: Vertigo and Nystagmus
Subacute: disequilibrium with head movements
What are the signs and symptoms associated with Bilateral Vestibular Hypofunction (Peripheral)? (3)
- No Vertigo
- Dizziness
- Disequilibrium with head movements
What are the signs and symptoms associated with Vestibular Nucleus and/or Cerebellar Involvement (Central) (5)
- Dizziness Varies
- CN Involvement
- Incoordination
- UMN Findings
- Pure Direction Nystagmus
What are the signs and symptoms associated with Non-Vestibular Causes of dizziness and Balance issues? (4)
- Dizziness
- Disequilibrium
- Age related loss of Vision
- Age related loss of Hearing
What diagnostic test is key to determining BPPV (Peripheral or Mechanical)?
(+) Positional Testing
What are the diagnostic tests for determining Unilateral Vestibular Hypofunction (Peripheral)? (4)
- ENG: calorics Decreased!
(+) HIT (Heparin Induced Thrombocytpenia)?
(+) DVA (developmental Venous Anomalies)?
+/- Hearing Loss
What diagnostic tests are key to determining Bilateral VEstibular Hypofunction (Peripheral) (5)
- ENG: Calorics Decreased
- (+) HIT
- (+) DVA
- +/- Hearing Loss
- Bilateral
What are the key diagnostic tests for determining Vestibular Nucleus and or Cerebellar Involvement (Central) (4)
- Imagining
- Saccades Abnormal
- Smooth Pursuit Abnormal
- (+) VOR Cancellation
What is the typical progression of BPPV (Peripheral or Mechanical)?
Remission, but may experience Reoccurrences
What is the prognosis for Unilateral Vestibular Hypofunction (Peripheral)?
Acute, Then improving
What is the prognosis of Bilateral Vestibular Hypofunction and Vestibular Nucleus/Cerebellar Involvement?
Varies
Upper motor neuron facial weakness presents how?
Contralateral side of the face
Below the level of the eye
Cranial nerve VII
Lower motor neuron facial weakness presents how?
Ipsilateral side of the face, the entire side.
CN VII Lesion
