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Pharma 2 > Lecture 7: Vestibular Disorders > Flashcards

Lecture 7: Vestibular Disorders Flashcards

1
Q

We need different body systems for posture, or the ability to stand upright against gravity. What are they

A

1) Vision
2) Vestibular
3) Somatosensation

They’re intragrated through the CNS and PNS to give us the ability to maintain upright.

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2
Q

The role of the vestibular system:
* Maintain clear vision during hd movement
* Determine head position in space
* Determine the speed and direction of head movement
* Critical for postural control; uniquiely identifies self-motion as different from motion in the environment (I can walk around room and know body is moving but vestibular system itself isnt)

Works as part of the sensory triad, in conjunction with vision and somatosensory inputs for postural stability
* Sensory information from all 3 systems is centrally integrated to determine appropriate postural strategies

A
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3
Q
A
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4
Q

NOTE: for the vestibular system

Not life threatening (aside from aggresive forms of neoplasm) but can cause significant disability, with a devastating sense of abnormal movement, visual instability and loss of balance

Symptoms of dizziness and imbalance cannot always be assumed to be an actual loss of vestibular function as they may also reflect inadequate sensory integration appropraite for the environmental context
* so it could be a sensory issue or something in another system that promotes balance and psoture
* Think if one of those other 2 systems in our triad is off

Comobrid dysfunction can affect functional recovery from a vestibular condition, especially if it affects the visual or somaosensory inputs
* If someone has diabetes and has polyneuropathy - impacts somatosensory system (sensation) + a vestibular deficit will just make balance and posture worse

Prior trauma, either physical or psychological, can also cause maladatption, resulting in responses to intervention that are inconsistent with typical recovery patterns

A
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5
Q

there are vestibular nucli throughout the CNS that work with the cerebellum and will process information in different areas of the CNS. Will project information outwards

A
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6
Q

KNOW: The sensory role of the vestibular system is perception of motion and orientation

A
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7
Q

What is the motor role of the vestibular system (3)

A

1) control eye movements
2) Gaze stabilization (ability to look at a target and hold gaze)
3) Maintain posture/equailibrium

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8
Q

what are the two sensory roles of the vestibular system

A

1) Perception of motion and orientation

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9
Q

NOTE: Togetehr our vestbiular system is postural, motor and oculomotor contorl

A
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10
Q

Compoenents of vestibular system

PNS: 2
CNS: 2
Reflexes: 3

A

PNS
* vestibule (sensory organ)
* CN 8 (vestibulocochlear)

CNS:
* Vestibular nuclei (in brainstem)
* Cerebellar pathways

Reflexes - combine both CNS and PNS to create involuntary rxns
* Vestibulo-ocular (VOR)
* Vestibulospinal (VSR)
* Vestibulocollic (VCR)

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11
Q

Which reflex stabilizes gaze during head motion?

A

Vestibulo-ocular reflex

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12
Q

What is the fastest reflex in the body?

A

Vestibulo-ocular reflex (VOR)

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13
Q

Which reflex generates compensatory eye movements?
* what are compensatory eye movements?

A

Vestibulo-ocular reflex (VOR)

EX: rotation of head to the left results in rightward compensatory eye movement (makes sense that this reflex also does stabilization of gaze)

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14
Q

Which reflex maintains vertical alignment of trunk?
* which side wil have flexor/extensors effects

A

Vestibulospinal reflex

When the head tips in one direction, the SC produces extensor effects on side. ti which head is bent and flexor effects opposite

notice the head wants to be upright

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15
Q

Which reflex stabilizes head in space by activating neck musculature?

A

Vestibulocollic reflex

Neck muscle activation to stabilize head in space, compensates for head displacement during gait

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16
Q

dilinating between these 3 reflexes will be on quiz

A
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17
Q

not going to hold us to the definitions

A
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18
Q

Ability to hold gaze/target on something thats moving
* tested w/ H test

A

Smooth pursuit

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19
Q

looking back and forth between multiple targets and keeping your gaze

A

saccades

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20
Q

object is stationary, not moving. stabilizing gait on something

A

visual fixation

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21
Q

ability to look at something while there is rotation/movement going on

A

optokinetic

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22
Q

Oscilatory beating of the eyes (involuntary) - only normal if its at the end ranges of their gaze and their gaze is strained.

A

Nystagmus

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23
Q

knowledge check: which reflex does stabilization of gaze?

A

VOR

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24
Q
A
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25
Q

Which part of the ear is a system of fluid filled w/ tubes and sacs
* also called

A

Inner ear

also called the labyrinth

we have two labyryniths 1 is boney the other is fuild

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26
Q

The labyrynth is responsible for what two functions?

A

Hearing / balance

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27
Q

Which part of the labyrinth is specifically responsible for hearing?

A

Cochlea (transmits sound to the brain)

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28
Q

where in the ear is tinitis formed?

A

cochlea

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29
Q

Which part of the inner ear is responsible for balance

A

The vestibular organs
* This is semicircular canals + otoliths

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30
Q

Which two things make up the vestibular organs?

A

Semicircular canals + Otoliths

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31
Q

Signals travel from labyrinth –> brain via which CN?

A

Vestibulocochlear nerve

Brain integrates these signals

Cochlea involvement = abnormal noise/inner ear = tinnitus

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32
Q

we have 3 coplanar pairs that orient our semicircular canals and orient our cells in the labyrinth

R/L horizontal pair
R anterior and L posterior pair
L anterior and R posterior pair

Turning head to the right = right vestibular nerve gets more signals and the L is decraesing its signals.

Our 3 pairs are either on a R horizontal axis or are on 2 diagonal axises

A
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33
Q

are the semicircular canals affected by gravity?
* What do they sense?
* How many in each ear?

A

No

Sense rotation

3 in each ear 6 total (horizontal, anterior, posterior)

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34
Q

Fluid that fills the semicircular canals

A

endolymph

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35
Q

which part of the semicirclar canals is dilated space/opening at the end of each canal; cilia/hair cells are located within ampulla, more specifically held in endolymph in a place called the cupula

A

Ampulla

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36
Q

Which part of the semicular canals is a gel-like bud, embedded with sensory hair cells, that sits within the ampullated (dillated) portion of each canal?

A

Cupula

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37
Q

What happens w/dysfunction of the semicircular canals?

A

Spinning or vertigo

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38
Q

Which part of the ear detects forward/backward head tilts and translation of the head (so it is affected by gravity)

A

Otoliths
* detect gravity and position in space

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39
Q

Which part of the ear is affected by gravity?

A

Otoliths

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40
Q

What are the two otolithic organs? (otoliths are in here)

A

Utrricle and saccule

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41
Q

KNOW: The otoconia are IN the otolith organs - should not be in the semi sircular canals
* this is when BPPV happens

A
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42
Q

where to semicricular canals originate?

A

Utricle

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43
Q

A feeling of pulling/shifting involves what part of the ear

A

Utricle dysfunction

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44
Q

Otoconia (that can get in the SSC) are smaller than a spec of dust

age related changes - hypertrophy, variability in size, fragmentation, fissured, putted, weakening of links - can help develop BPPV

Worse with females/osteoporosis (older age; but starts worsening in middle age)

A
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45
Q

Know: Otoconia should be in the otoliths
* belong in wall of saccule and floor of utricle

A
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46
Q

Nystagmus can be physiological (eyes straining to reach end range) or pathological

Nystagmus is named for its fast phase or side it beats fastest towards (R, L, up, down, torsion)

Slow phase is the side of dysfunction
* so its beating more toward the side thats more neurally intact

PNS dusfunction: beats quickly toward more enurally active side
* EX: L hypofunction = R beating. Hypofunction side is opposite; peripheral disorder

Side of torsion: one side will be stronger or present

CNS dysfunction = pure vertical; pure torsion
* so the beating is different if its CNS vs PNS

A
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47
Q

knowledge check: cochlea transmits sound to the brain

A
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48
Q

Where does the vertebral-basilar artery supply blood?
* What other 2 arteries play a role in supplying this area?

A

Components of the vestibular system

Posterior and inferior cerebellar arteries also play a role in supplying this area

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49
Q

What does the anterior inferior cerebellar arteries supply?
* Supplies it via what 3 arteries?

A

Supply the peripheral mechanism via the labyrinthine, common chochlear and anterior vestibular arteries

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50
Q

Vertebral artery test - tests for vertebral basilar insufficiency
* This position maximally stresses the opposite vertebral artery and decreases the space in the lumen of the artery
* Extension with contralateral rotation has been shown to decrease the diameter of the artery
* Diagnostic accuracy of the test = poor, negative test does not rule out VBI
* If the have any of the 5 D’s come on than were worried

A
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51
Q

What innervates the inner ear area
* this nerve subdivides. What does it turn into and waht does each branch innervate?
* What other nerve is very close and runs through this same area?

A

Vestibulocochlear

Divides into the vestibular nerve to semicricular canalas and chochlear nerve to the cochlea

Facial nerve (VII) runs right through this area as well

52
Q
A
53
Q

hearing: Sound enters external auditory meatus –> ossicles move –> causes fluid to move –> triggers hair cells –> converts to electrical signals –> to auditory (cochlear nerve) –> to brain

A
54
Q

Which portion of the ear is responsible for conductive hearing?

Which portion of the ear is responsible for sensorineural hearing?

A

External / middle ear = conductive

Inner ear = sensorineural

55
Q

What kind of hearing loss is trouble transferring sound waves along peripheral pathway?

A

Conductive

56
Q

What kind of hearing loss is damage in the inner ear or sensory organs or the auditory nerve?

A

Sensorineural

57
Q

What is a major recipient of outflow from vestibular nucleus complex, major source of inout for vestibular reflexes

A

Cerebellum

58
Q

Knowledge check: What is the major input for vestibular reflexes

A

cerebellum

59
Q

KNOW:

Frequency of dizzines increases w/ age

Approximately 10% of people older than 45 years visit their physicians complaning of dizziness, with rates increasing further in those older than 75 y/o

Hair cell loss occurs with aging, particullary in the ampulla

Demineralization and fragmentation of the otoconia, also increase w/ age, especially in those with osteoporosis and vitamin D deficiency

Neuronal loss in the vestibular nuclei is also estimated to occur at a rate of approximately 3% per decade from the age of 40 years

aging has a significant direct effect on vestibular function

dont need to know any of the #’s above

A
60
Q

where does ear hair cell loss occur the most w/ aging?

A

Ampulla

61
Q

Dont think shes going to ask anything here

A
62
Q

Treatment for vestibular

Reflects the spectrum of etiologies and depends on the nature of the underlying vesitbular disorder

A
63
Q

When vestibular symptoms are due to a peripheral vestibular lesion, functional recovery will begin within _ days to _ weeks through adaptive mechanisms of the brain

A

2 days - 4 weeks

If symptoms are severe, sedatives may be give, but ideally only for the first 24 hours

Use of antivert - can cause drowsiness

Rehab should begin within the first 3 days

Surgical itnervention is considered when symptoms are unrelenting and underling condition is determined bt is unresponsive to other medical measures

64
Q

Unilatearl peripheral vestibular system lesion, but the CNS is intact. Is recovery of functional mobility possible?

A

Yes

65
Q

Complete bilatearl vestibular loss can occur as a result of use of ototoxic medications but is realtively rare. What is the prognosis like?

A

POOR

66
Q

KNOW: Prognosis for flucuating conditions such as endolympahtic hydrops or menieres disease is highly variable

recovery rate in a central vestibualr system disorder causing dizziness or disequlimbrium depends on the nature of the lesion and concomitant neurlogic dysfunction
* whats causing the lesion (is it a tumor - maybe we can remove it)

A
67
Q

For vestibular - in order to determine if theres a central cause of the pts symptoms, the therapist must carefully examin the CNS by testing of function associated w/ cranial nerves, cerebellum, brainstem and cortical connections

Often, noth central and peripheral lesions can be identified.

Also evaluate the MSK and neuromuscular systems becayse compensatory movements releated to deficits in these systems may mimic vestibular dysfunctions or impact recovery

A
68
Q
A
69
Q

Knowledge check: who would have the most favoriable prognosis
* unilatearl peripheral lesion like BPPV would have the best prognosis

A
70
Q

Illusion of movement, false sense of rotation or linear movement

A

Vertigo

71
Q

Sensation of being off balance, not observable

A

Disequilibrium

72
Q

Unsteadiness, obseravble

A

Imabalnce

73
Q

Moving objects in the environment, subjective

A

Oscillopsia
* this is more theres somethign wrong w/ their eyes

74
Q

Fainting feeling

A

Presyncope/Lightheadedness

75
Q

2 autonomic signs

A

Diaphoresis, emesis

76
Q
A
77
Q
A
78
Q

knowledge check: sensation of being off balance but not observable

A
79
Q

In peripheral vestibular disorders
* Unilateral hypofunction: stable vs unstable
* or
* Bilatearl hypofunction

central vestibular disorders

Non-otogenic dizziness

A
80
Q

In peripheral vestibular disorders how long does the event last what then what occurs

A

event lasts days then compensations occurs

81
Q

Peripheral vestibular disorders can have unilateral hypofunction that can be stable (also called fixed) and unstable

3 examples of of stable hypofunction

4 examples of unstable unilatearl hypofunction

A

Stable: Weak VOR. This is what we treat
1) vestibular neuritits
2) Anterior vestibular artery ischemia
3) Labyrinthits

Unstable
1) Menieres disease
2) Acoustic neuroma
3) Superior canal dehiscene

Research shows PT is not effective in unstable flucuating conidtions

82
Q

Menieres disease is a peripheral vestibular disorder thats unilataeral hypofunction. Is it stable or unstable?

s/s
* differentaiting factor

right is healthy other is swollen

A

Unstable

differenitating factor is the auditory symptoms

83
Q

Overaccumulation of endolymph and resulting compromise of the perilymphatic space
* whats a form of this disease?
* Men or women more
* age
* genetics?

A

Endolymphatic hydrops

Meniere syndrome is thought by many to be a form of endolymphatic hydrops
* herilymphatic space is compromised

caucasian women are most prone to meniere syndrome

The peak incidence of meniere syndrome is in the 40-60 year old age group

Whether the variability in prevalence rates is caused by differences in environment, genetics, or diagnostic criteria is unclear

Familial occurence of meniere syndrome has been reported in 10% to 20% of cases

Genetic inheritance plays a role

84
Q

presentation of endolympahtic hydrops and meniere disease

A

clusters of attacks may be separated by periods of long remission

Balance function between attacks can be normal

Over time there is a gradual decline in the function of the vestibular system and complaints of imbalance and mild symptoms relaeated to a unilateral dysfunction become common

The hearing loss in menieres disease is flucuating, low-frequency sensorineural loss early in the clinical course
* eventually, the loss becomes irreversible, often progressing in severity with involvement of higher frequencies and loss of speech discrimination

85
Q

Syndrome of vertigo and oscillopsia induced by loud noises or by stimuli that change middle ear or intracranial pressure in patients with a dehiscence of bone overlying the superior semicircular canal
* does it need surgery?

A

Superior semicircular canal dehiscence syndrome

Unilatearl hypofunction (unstable)

needs surgery

As seen in fistulas, Tullio phenomenon (eye movements induced by loud noises) or heenebert sign (eye movements induced by pressure in the external auditory canal) develop and often there is chronic disequilibrium

86
Q

Bilatearl hypofunction - this is now both ears
* ototoxicity, meningitits, sequential vestibular neuritits, progressive disorders, autoimmune disorders, chronic inflammatory peripheral polyneuropathy, congenital loss, and neurofibromatosis
* Most common idiopathic

Treatment: challenging, compensation for lost vestibular function

A
87
Q

When certain medications someone is on severealy damages the vestibular system - think antibiotics like amingoglycoside and streptomycin and gentaminicin

A

Ototoxicity

88
Q

In ototoxicity where does the pathology from the antibiotics occur?
* what is one of the most debilitating early symptom
* when are they unable to stabilize vision?
* is damagege perminant?

A

Damage to the hear cells in the inner ear (permanet) can result in complete loss of vestibular function within 2 to 4 weeks after these drugs are given

retinal slip = early symptom

unable to stabilize vision during head movement

damage is permanent and that the recovery of function of the vestibular mechanism is limited

89
Q

Viral infection is the 2nd most common vause of vertigo and usually affects what nerve unilatearlly?

A

Vesitbular nerve
acute unilatearl vestibulopathy = vestibular neuritits

vestibular neuritits can be a partial unilatearl vestibular lesion, and this partial lesion can affect the superior division of the vestibular nerve, which includes and afferents from the horizontatl and anterior semicricular canals

The use of antibiotics in general has decreased the incidience of bacterial infections affecting the vestibular system

90
Q

KNOW: Acute unilatearl vestibular nueronitits causes sudden onset of vertigo, spontaneous horizontal and torsional nystagmus, nausea, and vomitting

The person will immediately expereince intense disequilibrium, and hist or her ability to perceive position and motion will be profoundly disturbed

A
91
Q

whi acute unilatearl vestibular neuronitits what is it like w/ the eyes closed?

What about open?

lateralpulsion away to to the side of lesion?

A

closed = illiusion of self spinning

Eyes open - illusion of environment spinning

NOTE: they’ll also have lateropulsion to the side of the lesion - lean to the side of the lesion

92
Q

Medications are used for symptoms of acute vertigo and include antihistamines, anticholinergic agents, antidopaminergic agents, steriods, and antivirals such as acyclovir

Gluccocorticoids adminsterid within 3 days after onset of vestibular neuronitits improve long-time recovery of vestivular function and reduce length of hospital stay

PT plays a role

slow recovery 4-6 months

A
93
Q

Knowledge check: acute vistibular neuritits lateral pulsion =

A

side of the lesion

94
Q

Benign Paroxysmal Positional Vertigo (BPPV)

Benigns = not life threatening

Paroxysmal = it comes on suddenly, brief spells or intensification of symptoms

Positional - it gets triggered by certain head positions or movements

Vertigo - a false sense of rotational movement

A
95
Q

What is the most common cause of vertigo

A

BPPV

96
Q

who is more affected by BPPV men or women?

A

Women

NOTE: most is idiopathic
* also had traumma and viruses can cause it

97
Q

BPPV is resolved for 20% of people within 1 month and 50% in 3 months
* however it reoccurs in 40-60% of cases

BPPV may trouble the individual intermittently for years, but in this condition, a close examination of potential causes will often identify an underlying medical disorder, and recurrences decline when the underlying disorder is managed

A
98
Q

BPPV

change in head position causes the symptoms

objective findings on testing –> nystagmus

canalithiasis vs cupulolithiasis
* Canalithiasis: free floating otoconia in SCC, latency 3-5 seconds, nystagmus and vertigo to follow, fatigues with repetition, more common
* Cupulolithiasis: otoconia stuck in cupula of affect SCC, immediate onset of nystagmus and vertigo, long lasting symptoms (greater than 1 minute), weaker nystagmus

posterior canal = 85-95% of the time

A
99
Q

Clinical manifestations of BPPV
* strong sense of falling or spinning out of control
* Complain of breif episodes of vertigo precipitated by head movement in a specific direction such as bending over, looking up to take an object off a shelf, tilting the head back to shave, lying back to get a haircut, or turning the head rapidly while backing up a car

Episodes of vertigo occur suddently and typically last 20 seconds, but no more than a minute

Important to note that vertigo or the true sensation of the “room spinning” is not always present in BPPV. Some patients only report lightheadedness, sensation of floating, dizziness, imbalance, and/or nausea.

this is peripheral

A
100
Q

knowledge check: how long do episodes of BPPV last?

A

1 few seconds (20-60 seconds)

101
Q

What are symptoms like w/ Mal De Debarquement syndrome?
* when is it worst
* what is it triggered by?
* how long do symptoms last
* what age / sex

A

Syndrome that is named essentially for the symptoms releated to “getting off the boat” - rocking sensation worse during rest

Triggered by a long time spent on a ship, such as during a cruise, or by an extended train ride

The complaints occasionally occur after international or extended air travel, especially if there is turbulence

Dizziness and disequilibrium that usually subside within hours after exiting a boat, train, or plane become presisent and can last for weeks, months or even years

Women in their third and fourth decade represent the highest percentage of people reporting symptoms

Poor prognosis tends to limit activity or overmedicate to dapmen the sensation
* because you feel so sick that you basically cant move

102
Q

what is a fistula?

A

abnormal connection between two areas in the body

103
Q

What is a perilymph fistula?
* what can it cause
* what is it caused by
*

A

An abnormal communication of the innter and middle ear spaces

can cause vertigo, vestibular and/or hearing issues

Some stupids report veztibular symptoms as the major presenting complaint, whereas others idnicate hearing loss equal to or more common than balance releated symptoms

caused by pressure changes internally or externally, congenital malformations, prior ear surgery

conjugate contralateral slow deviation of the yes with vertigo occurs with positive pressure applied to the suspected ear

reduction in vesitbular releated complaints has been reported in more than 50% of surgeries. Hearing is imporved about 25% of the time

Head elevation during bed rest, laxatives to reduce the risk of increased intracranial pressure, and monitoring of both hearing and vestibular function

In those isntances in which hearing loss worsen or vestibular symptoms persist, surgical exploration is warranted

104
Q

On quiz surgery indicated for superior canal diabesis (i spelled this wrong, in notes prior)

A
105
Q

is nystagmus longer in a central or peripheral vestibular disorder?

A

central

106
Q
A
107
Q

KNOW: In mild traumatic brain injury BPPV is common

A
108
Q

On quiz: Mild traumatic brain injury = GCS 13-15

A
109
Q

how long does it take to recover from a milk traumatic brain injury?

A

7-10 days

110
Q

KNOW: w/ a mild TBI can develop post concussion syndrome (deficits for months to years) if initial symptoms not resolved in a couple weeks after injury

most common setting for mild tbi = sports

Recovery from mTBI should include a graded progression of icnreasing PA/EX that does not exacerbate symptoms and balance rest

A
111
Q

Knowledge check: Mild to traumatic brain injury on glasnow scale

A

13-15

112
Q

with non-otogenic dizzines what are symptoms lke what are vestibular tests like?

A

symptoms = vague

vestibular tests = normal

113
Q

Is there 1 set test for Non-otogenic dizziness?

A

No definititve test, eval upper quarter if no apparent neurological or otologic causes for the symptoms

address impaired cervical kinesthesia along with MSK impairements
* the awareness of the cervical spine during movement

The cervical spine plays a role in gaze stability and postural contorlm focus on pain reduction and resotration of cervical mobility (not largely on VRT), most dont complain of vertigo but of imbalance/lightheadedness/disequilibrium

cervical ROM, pain
* Limit positional testing
* Impact VOR movement
* Fear avoidance behaviors
* Clear VBI

114
Q

What is disuse disequilibrium?

A

Similar to deconditioning with fear of falling
- typically odler pt

functional effects of aging nervous system = skeletal mm atrophy, less precise contorl of movement, decreased sensitivity of somatosensory system, processing speeds slow

Disuse deconditioning can be age-releated
* when we get older we arent stimulating the vestibular system as much which causes it to change its tolerance

115
Q

need to carify these symptoms w/ the pt

syncope = fainting

might not even be a vestibular issue = might be a BP issue

A
116
Q

chronic subjective dizziness and PPPD

Might be a maldaptive loop where some trauma happened

stuck in this dizziness loop where theres not anything physiologically wrong anymore
* need to work on ways to increase confidence / mobility

PPPD = persistent postural perceptual dizziness
* Starts shortly after an acute event that leads to vertigo/balance issues etc
* Presentation: Dizziness w/o vertigo and fluctuating unsteadiness that is provoked by environmental or social stimuli

treatment = vestbiular habiutation, cognitive behavior therapy, medication

A
117
Q
A
118
Q

Primary carcinoma can directly involve the end organ, the midle ear, or the mastoid

A

Neoplasia

119
Q

the most common tumor of the middle ear, arising from the chemoreceptor system of the ninth through 12th cranial nerves and producing focal symptoms

A

glomus tumors

120
Q

tumor that arises from the nerve sheath of the vestibular nerve, The term acoustic neuroma is commonly used to describe this tumor, especially with regard to surgery.

A

Schwann cell tumors

acoustic neuroma = vestibular schwannoma

121
Q

meningioomas can cause displacement of cranial nerves

Glimoas from brainstem interupting craniala nerves

metastatic neroplasms

A
122
Q
A
123
Q

know icnreased intracranial pressure will lead to a severe HA

A
124
Q

knowledge check: another name for an acoustic neuroma

A

vestibular schawnoma

125
Q

know icnreased intracranial pressure will lead to a severe HA – maybe not all the ins and outs here

A
126
Q
A

Pharma 2 (23 decks)

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