Module 8 Flashcards
The anterior and posterior semi circular canals are oriented
Vertically at right angles to each other
The horizontal semi circular canal is oriented at a
30 degree angle from horizontal plane
The macula of the utricle lies
Horizontally on the floor of the utricle
The otolithic membrane is above
The gelatinous layer that embeds the tips of hair cells
The otoloconia adds ___ to the otolithic membrane
Weight
The otoconia allows for increased sense of _____ and ___
Gravity and head orientation
The otoconia also increases the ability to detect ____, _____ and ______
Motion, inertia and horizontal acceleration
How is the utricle different from canal structures
It responds to linear motion instead of angular motion
The macula of the saccule lies in a
Vertical position
The macula of the saccule detects
Vertical linear acceleration
The weight otolithic membrane lags behind the
Stereocilia and kinocilium
Head orientation causes a combination of stimulation to ___ and ___ of ___ ears
Utricle and saccula of both ears
How does the brain interpret head orientation
Compare the inputs of the utricle and saccule to each other and the input form eyes and cervical stretch receptors
What is the ampulla
The localized dilation at one end of the semi circular duct
What is the crista
A patch of innervated hair cells found at the base of the ampulla
The hair cells in the crista are _____ oriented in a ___ direction
Stereo cilia, consistent
The stereocilia of the crista is embedded in a
Gelatinous cupula
During head rotation _____ in the semi circular ducts initially lags behind due to _____
Endolymph, inertia
What happens to the endolymph and cupula during head rotation
The cupula is deflected in the opposite direction of head movement and the endolymph fluid pushes the cupula - hair cells get stimulated and transmit corresponding signal
During head motion ____ acceleration of endolymph in the semicircular canals moves fluid back and forth in direction of ______ which stimulates vestibular receptors to ________
Angular, spinning, signal the brain that the head is moving
The vestibular ocular reflex involves how many pathways
3
The first neuronal pathway of the vestibulo ocular reflex is
Peripheral vestibular organs to the vestibular nuclei - lateral, medial, superior and inferior
The vestibulo ocular reflex second neuronal pathway
Oculomotor nuclei
The third neuronal pathway in the vestibulo ocular reflex
Extra ocular muscles
The vestibulo ocular reflex operates by
Generating eye movements at the same speed but in opposite direction to head movement
What is the function of the vestibulo ocular reflex
Stabilize the image on the fovea during head movement
The vestibulo occular reflex allows a person to
To see a sharp and clean image even during movement
What is impulsion
The sensation that the body is being hurled or pulled in space
What is oscillopsia
The visual illusion of a stationary object moving back and forth or up and down
Nystagmus is
Rhythmic oscillations of the eyes and is an abnormal response
What are the brain stem/cerebellar symptoms of central disorder
Diplopia, dysphagia, dysarthria, dysmetria
Acute vestibulopathy first manifests as an insidious onset of
Vertigo
Symptoms of acute vestibulopathy
Vertigo, visual disturbances, oscillopsia, nausea, vomiting, imbalance, brain fog and fatigue
What are the signs of acute vestibulopathy
Nystagmus, gaze instability, coordination deficits, gait ataxia
The prevalence of vestibulopathy in the 7th decade of life
49.4%
Prevalence of vestibulopathy in those in the 8th decade of life
68.7%
Prevalence of vestibulopathy in the 9th decade of life and over
84.8%
What is brain fog
Abnormality in regulation of overall level of consciousness that is mild and less severe than a delierium
What are the risk factors for vestibulopathy
Trauma/surgery to head or neck, allergies, exposure to ototoxic medications, migraine associated dizziness, cerebrovascular disease, cerebrovascular accident, central nervous system disease
Vertigo is commonly due to an imbalance of
Tonic vestibular signals
Typical areas associated with vertigo include
Inner ear, middle ear, brain stem, cerebellum
Vestibular hypo function is
Unilateral damage to the peripheral vestibular system
Causes of central lesions include
Ischemia of brain stem, cerebellar infarcts, infarct of medulla and MS
Signs of central lesions include
Impaired saccades, smooth pursuit, and optokinetic nystagmus
Central lesions or peripheral lesions have neurological signs
Central
Peripheral vestibulopathy does not have
Neurological signs
Peripheral vestibulopathy Often involves
Tinnitus and hearing loss
Symptoms in peripheral vestibulopathy are more severe when there is
Nausea and vomiting
Peripheral vestibulopathy develops acutely or chronically
Acutely - they are intermittent and short lasting
Cervical vertigo is similar to
BPPV
Cervical vertigo is triggered by
Head rotation relative to body while in upright posture
In postural hypotension systolic BP is below ___ and diastolic is below ___
20 and 10
Endolymphatic hydrops is
An abnormality in quantity, composition and or pressure of endolymph
Primary idiopathic endolymphatic hydrops is also called
Ménière’s disease
Ménière’s disease is characterized by
Episodic attacks of sustained vertigo, fluctuating hearing loss, a feeling of fullness or pressure in the ear and tinnitus
In Ménière’s disease the duration is typically ________ and more _____
Longer, Disabling
In Ménière’s disease there is protracted _____ and ____
Nausea and vomiting
How does semi circular canal orientation cause different canal stimulation
By head rotation in different planes
Inner ear infections causing vestibular neuritis or labyrinthitis are more commonly form
Viral not bacterial
Vestibular neuritis initially experience _____ of a ____ onset,
Vertigo, gradual
Difference in hearing between vestibular neuritis and labyrinthitis
No hearing loss in vestibular neuritis but there is hearing loss and tinnitus with labyrinthitis
Spontaneous nystagmus is present in vestibular neuritis or labyrinthitis
Vestibular neuritis
Symptoms happen _____ in labyrinthitis
Quickly
Oscillopsia is commonly seen in labyrinthitis true or false
True
Labyrinthitis may cause
Endolymphatic drops
Most common vestibular disorder
BPPV
BPPV is
A syndrome characterized by short episodes of vertigo in association with rapid changes in head position
Prognosis for BPPV is
Good
What type of BPPV is more common and why
Posterior canal on the right because people tend to sleep on their right
Most common age of onset of BPPV
60
Women to men ratio for BPPV
3:1
In patients with chronic vestibular disorder __% had fell one or more times in the past year
53%
Symptoms of BPPV occur when
Otoliths or fragmented endolymph particles migrate from area normally present into PC SCC
BPPV - Trapped otoliths causes ___ changes in PC SCC
Intertial
Most common form of PC BPPV
Canalolithiasis
Intraoperatibe observation in Canalolithiasis showed
Free floating debris in endolymph of SCC
In cupulolithiasis
Otoconia from the utricle are adherent to the cupula and deflect cupula inducing a gravitational effect on crista
In cupulolithiasis position dependent movements (gravity) cause
Increased deflection of involved canal
In cupulolithiasis increased stimulation remains as long as
Canal is in Gravity dependent position
Nystagmus via stimulation of PC SCC Is of this type
Mixed torsional and vertical movement
Nystagmus via stimulation of PC SCc is a ___ torsion
Up beating
Upper pole of eye beats toward
Dependent ear
Vertical component of nystagmus beats towards
Forehead
Rate of nystagmus begins ___ increasing in ___ and then decreasing in ____
Gently, intensity, intensity
Nystagmus up beating results in activated
Ipsa lateral superior oblique and contra lateral inferior rectus
Nystagmus causes tonic _______ deviation of eyes with torsion in direction of _______
Downward, upper most ear
Upper pole of eyes beats towards _____
Lower most ear
In BPPV there is usually no ___ loss
Hearing
Nystagmus in BPPV fatigues after __ seconds
60
BPPV has the ___ duration : seconds
Shortest
Is nausea present in BPPV
No
Treatment of BPPV
Canal repositioning maneuver
Treatment of vestibular neuritis
Symptomatic nausea treatment and steroids
Treatment of labyrinthitis
Symptomatic nausea treatment and steroids
Treatment of Ménière’s disease
Nausea treatment, salt restriction and diuretics
How to asses orthostatic hypotension
Measure BP and hr after 5 minutes in supine, then again immediately standing and again after 3 minutes of standing
Positive orthostatic hypotension readings
SBP lowers by 20 mmHg or DBP lowers 10 mmHg
How do you perform the head impulse /thrust test
Head is rapidly turned to one side and then to other side while watching eyes for prescience or a scene of corrective movement
Positive head thrust is when
When turned to effected side there is a corrective saccades to re fixate on visual target - VOR fails
BPPV history that leads to diagnosis
Repeated episodes of vertigo with changes in head position
Physical examination of BPPV (3)
Vertigo associated with nystagmus provoked Dix hallpike , latency period between completion of Dix hallpike and onset of vertigo and nystagmus is 5-20 seconds , provoked vertigo and nystagmus resolve in 60 seconds
How to perform Dix hallpike
Start in long sitting, neck is extended 20 degrees and rotated 45 degrees to involved side, quickly moved to supine and observe for rotational nystagmus
Alternate Dix hallpike
Seated at side of table. Head rotated 45 degrees away from involved ear, patient moved to side lying on the involved side
The supine roll test is used to assess for
Lateral canal BPPV
In lateral BPPV Dix hallpike will be
Negative
Phenothiazine are used to control
Nausea and vomiting
Anticholiniergics are used to
Prevent nausea, vomiting and motion sickness
Benzodiazepines are a ______ used to treat
Central nervous system depressant, anxiety and chronic problems
Three principles of vestibular rehabilitation training
Adaptation, substitution and habituation
Vestibular adaptation involves
Readjusting gain of vestibulo ocular reflex or vestibulo spinal reflex
Vestibular substitution uses
Alternative strategies to replace lost vestibular function , used to describe general recovery from unilateral vestibular deafferentiation syndrome
Vestibular substitution is also called
Vestibular compensation
Vestibular habituation
Decreases Symptoms via receptive symptom provoking head movements
Adaptation exercises consist of
Repeated head movements while focusing on a target to develop compensatory saccadic eye movement
Saccadic eye movement provide _____ for an impaired VOR
Motor substitution
Two kinds of saccades
Insufficient amplitude and saccades back toward target
In insufficient amplitude
Eyes drift to target
In saccades back toward target
It is generated in the opposite direction to head rotation back toward target
Ankle strategy involves upper and lower body moving in ____ direction
Same
Hip strategy involves upper and lower body moving in
Opposite directions
Falling is a consequence of
Bilateral vestibular hypo function
Those over 65 with bilateral vestibular loss should
Use AD
Adaptation implies a _____ where’s habituation Is an
Return to normal, attenuation of symptoms
Habituation exercise example
Brandt - daroff
Habituation exercises are inappropriate for patients with
Bilateral vestibular loss
Habituation effect is s____ for older adults
Slower
For habituation perform ___ per day
Less than or equal to 4 movements
Symptoms should dissipate within ____ after each rep of habituation exercise
A minute
Frequency of habituation exercises
2-3 times per day
Habituation exercises may take _ weeks for symptoms to go away, continue for _ months and perform __ per day thereafter
4, 2-3, once
Modified eply is used to treat
Posterior SCc and anterior SCC
Canalith repositioning maneuver is also called
Particle releasing maneuver
Mastoid vibration is no longer used true or false
True
Crp is more effective than placebo with a ___ success after one session
80%
What is the eply maneuver
Start from Dix hallpike test position, bring supine and turn head 90 degrees toward uneffected side, turn head and trunk 90 degrees in same direction and then move back up to sitting
Maintain each position in eply maneuver for _ to _ minutes or until
1-2 , induced nystagmus and vertigo are resolved
What is the clinical test for sensory interaction in balance (CTSIB)
Examines body sway for 20 seconds under six different sensory conditions
The dizziness handicap inventory is a
25 question self assessment
The dizziness handicap scale has a max score of
100
The greater the score on the dizziness handicap inventory means
Greater perceived handicap
What is the clinically significant change on the dizziness handicap inventory
18 points
The BPPV reoccurrence rate is
15% per year up to as high as 50% at 5 years
Bilateral PC SCc is more likely to be encountered after
Head trauma
Vestibular compensation results from
Active neuronal changes in the cerebellum and brain stem in response to sensory conflicts produced by vestibular pathology
VRT does not regenerate or treat the
Damaged vestibular end organ itself
VRT focuses on the
Plasticity of the CNS
Best stimulus for increasing the gain of vestibular response is
Error signal induced by retinal slip
What is retinal slip
Image motion on retina during head motion
Retinal slip is induced by
Horizontal or vertical head movements while maintaining visual fixation on a target
Repeated periods of retinal slip induce
Vestibular adaptation
In substitution for gaze stabilization the ____ reflex will substitute the VOR
Cervical ocular reflex
The COR is
An ocular stabilization reflex that is elicited by rotation of the neck
Cawthorne cooksey exercise for saccade
Moving only the eyes imagine two targets close enough together while looking directly at one, quickly switch looking between the two targets without moving the head
Pursuit cawthorne cooksey is when
Put thumb out in front and move side to side not moving head w
Enhancing gaze stability exercises are performed
4-5 x per day for 20-40 minutes per day including 20 minutes of balance and gait
Central or peripheral lesion will cause prolonged period of therapy
Central
Patients age does ___ effect the final level of recover
Not
Age may ______ time required to receive max benefit
Prolong
If on medications, outcome is the ___ but it takes ____
Same, longer
Stage at which treatment is initiated should be
Earlier for better results
Most common complication of BPPV is
Canal conversion or switch
