Session 3: History taking and balance Flashcards
what is the vestibular system?
the part of the inner ear responsible for balance
what are vestibular lesions?
damage or dysfunction to the vestibular system
how can we tell there are vestibular lesions?
they disrupt the normal balance functions leading to symptoms like: vertigo, dizziness and imbalance
Name 6 vestibular lesions?
1- BBPV (benign paroxysmal positional vertigo)
2- Labyrinthitis/ Vestibular Neuritis
3- Meniere’s Disease:
4- Perilymph Fistula
5- SSCD (Superior Semicircular Canal Dehiscence)
6- Ototoxicity
what is BPPV caused by?
Caused by displaced otoconia (small crystals in the inner ear) affecting the semicircular canals, leading to vertigo triggered by head movements.
what is labyrinthitis?
Inflammation of the entire labyrinth (inner ear), which can affect both balance and hearing.
what is Vestibular Neuritis?
Inflammation of the vestibular nerve, primarily affecting balance without impacting hearing.
what is Meniere’s disease?
A disorder involving excess fluid in the inner ear (endolymphatic hydrops) leading to episodes of vertigo, tinnitus, and fluctuating hearing loss.
What is Perilymph Fistula?
A tear or defect in the bony structure of the inner ear or in the round or oval windows, allowing perilymph (inner ear fluid) to leak into the middle ear, causing dizziness and hearing changes.
what is SSCD?
An opening in the bone that covers one of the semicircular canals, leading to abnormal fluid movement and causing vertigo, hearing issues, and heightened sensitivity to internal sounds.
what does BPPV stand for?
Benign- its not life threatening
Paroxysmal- it comes on suddenly and in brief spells
Positional- triggered by certain head
movements and positions
Vertigo- a false sense of rotational movement
what is a common cause of dizziness?
BPPV
what percentage of all dizziness is attributed to BPPV?
20%
how common is BPPV among older adults?
about 50% of all dizziness is attributed to BPPV
what is the mechanism that causes BPPV?
1- otoconia from the utricle become detached form their gel membrane and move through the endolymph
2- most commonly settling in the Posterior SCC or more rarely in the anterior or horizontal semicircular canals
3-the detached otoconia shift when the head moves
4-this stimulates the cupula to send false signals (nerve ending excitation) to the brain which creates a sensation of vertigo (normally lasting less than 1 minute)
what are causes of BPPV?
1- head injury ( fall or car accident) can dislodge otoconia from their normal position in the utricle, allowing them to migrate into the semi-circular canals
-2degeneration of the vestibular system (aging= deterioration of vestibular system=more likely dislodged otoconia=BPPV)
-3idiopathic (without clear reason)
4-secondary to vestibular labyrinthitis (inflamed inner ear structures= disruption of normal functioning of vestibular system= dislodgement of otoconia)
5-secondary to Meniere’s disease ((Meniere’s disease+ fluid build up in inner ear = pressure changes= displacement of otoconia= BPPV)
6-secondary to minor strokes of the anterior inferior cerebella (rare) - (minor stroke affecting area of brain controlling balance = disruption of vestibular function= dislodgement of otoconia- BPPV)
what are some symptoms of BPPV?
1-rotatory vertigo
2-head and body movements: rolling over in bed, getting up from bed, bending over, quick head movement
3-sensation of falling/ sinking
4-disorientated
5-veering off to one side
what are the treatments from BPPV?
2- repositioning manoeuvre; Epley Manoeuvre
3- post Epley instructions
4- home exercises: Brant Daroff exercises
5- refer back to ENT from canal plug surgery (RARE)
how does the GOLD standard Dix Hallpike test work?
- assesses how the eyes respond to specific head movements
- a positive result causes characteristic eye movement (Nystagmus)
What is the Epley Maneuver, and how does it help?
involves specific head and body movements designed to move dislodged (flush otoconia from the semi-circular canals back into their proper position in the utricle
What are post-Epley instructions?
after performing the Epley maneuver, patients are give post- Epley instructions to help prevent the reoccurrence of symptoms including:
- avoiding sudden head movements
-sleeping in a slightly elevated position (using extra pillows) - staying upright for a specified period after the maneuver
- may be asked to do Brant-Daroff exercises
What are Brandt-Daroff exercises?
home exercises for patients with BPPV, designed to help the brain adapt to changes in balance and reduce symptoms, they involve repeated head movements that encourage the otoconia to settle back in their proper places
what is the canal plug surgery?
involves blocking the affected semicircular canal to prevent the sensation of vertigo
What is the difference between vestibular Neuritis and Labyrinthitis?
VN- inflammation of the vestibular nerve
Labyrinthitis- Inflammation of the vestibular organ itself
How common is Vestibular Neuritis and Labyrinthitis?
accounts for 5% of all dizziness and affects all ages
Symptoms of VN/Labyrinthitis
- Sudden, severe vertigo (spinning/swaying sensation)
- Vertigo can last up from a several days to a couple of weeks. and they can make a full recovery or even have symptoms for months.
- Random attacks of dizziness
- Balance difficulties
- Nausea, vomiting
- Concentration difficulties
Labyrinthitis (same symptoms as above) but also
- Hearing loss
- Tinnitus
what are some causes of VN/Labyrinthitis?
- Unknown- in many cases, no definitive cause can be identified for an individual
*the following are some of the well recognised causes:
- Viral infection of the inner ear
- Viral infection which has occurred somewhere else in the body.
Example: Herpes virus, measles, common flu.
what are some Treatment of VN/Labyrinthitis?
- Medication
- Vestibular suppressants – Betahistine - Stop the incorrect balance
information - Anti – emetics (used for nausea)
- Treating the virus – Antiviral medicine - Acyclovir
- Vestibular rehabilitation
what age ground does Meniere’s affect?
age 40-60 but can affect anyone
how common is Meniere’s disease?
quite rare condition- 1 in 1000
what are the symptoms of Meniere’s disease?
- Dizziness or vertigo (attacks of a spinning sensation)
- Hearing loss- intermittent mainly at the times of vertigo. loud sounds may sound distorted and may cause discomfort. Usually the HL involves the lower frequencies but eventually also the higher. Whilst HL fluctuates, it becomes more permanent as the disease progresses.
- Tinnitus (a roaring, buzzing, or ringing sound in the ear)
- Sensation of fullness in the affected ear
- Symptoms tend to come and go together with episode lasting from 20 mins to 8-12 hours
What are the causes of Meniere’s disease?
-unknown
– Research suggest: Too much endolymph being produced, blocked
endolymphatic duct resulting in inefficient drainage of the
endolymph
what are the treatments of Meniere’s disease?
reduces vertigo in Ménière’s disease by decompressing the endolymphatic sac and, in some cases, inserting a shunt to drain excess inner ear fluidMedications: Vestibular Suppressants, Anti- Emetics, Diuretics (to control fluid balance)
- Diet control may also reduce the amount of fluid in the inner ear and ease symptoms. avoid foods like salt, chocolate, caffeine and alcohol.
- VR to control symptoms in between attacks
- Hearing aid
- Intratympanic Gentamicin- Gentamicin selectively damages the vestibular hair cells in the affected ear, reducing vestibular function and suppressing vertigo.
- Surgical intervention:
Labyrinthectomy – Destruction of the labyrinth– removing the balance portion of the inner ear thereby removing balance and hearing function of the effected ear. This procedure is only performed if you have near total/ total HL in affected ear.
Endolymphatic Shunt (endolymphatic sac procedure as the endolymphatic save plays a role in regulating inner ear fluid levels and during the procedure the sac is decompressed which can elevate excess fluid levels. in some cases this procedure is coupled with a shunt which drains excess fluid from your ear. )
- Grommet insertion- ventilating the middle ear, reducing fluid buildup, and relieving pressure, which improves hearing and reduces infections
What is Perilymph Fistula (PF)?
-Tear or defect in the bony capsule of the labyrinth or in the round or oval windows. This small opening allows perilymph fluid to leak into the middle ear.
- Changes in air pressure occurring the middle ear, like ears popping in plane, do not effect the inner ear but with PF, changes in middle ear pressure directly effect inner ear, stimulating balance or hearing structures within.
what are the symptoms of Perilymph Fistula (PF)?
- Ear fullness, - Fluctuating or ‘sensitive’ hearing, – - Vertigo (without the spinning), motion intolerance,
- Hearing loss, symptoms get worse with changes in altitude.
what is SSCD?
An opening in the bone that covers one of the semicircular canals, leading to abnormal fluid movement and causing vertigo, hearing issues, and heightened sensitivity to internal sounds.
what causes SSCD (Superior Semicircular Canal Dehiscence)?
- True cause of SSCD is unknown: Congenital or may have occurred during the development of the
inner ear. - Ear infections or head trauma.
what causes Perilymph Fistula (PF)?
- Head trauma.
- Rapid and intense changes in intracranial or atmospheric pressure such as SCUBA
diving, weightlifting or childbirth. - surgery
what are the symptoms of Superior Semicircular Canal Dehiscence (SSCD)?
“LOUD PRESSURE TRIGGERS VERTIGO AND MOVES OBJECTS”
- LOUD: Sensitivity to loud sounds.
- PRESSURE: Fullness/pressure in the ears.
- TRIGGERS: Symptoms triggered by pressure changes (e.g., coughing, sneezing, straining).
- VERTIGO: Dizziness or vertigo.
- AND: Autophony (hearing your own voice or internal sounds loudly).
- MOVES OBJECTS: Oscillopsia (stationary objects appear to move).
what is the treatment for SSCD?
surgery- plugging the dehiscence
what is the cause of balance pathologies?
-there’s lots of different causes including:
-ageing
-cardiovascular
-neurological
-vestibular etc
Why is history taking a vital part of a vestibular assessment?
History taking is crucial because it can help diagnose the condition. About 80% of the diagnosis comes from the patient’s history.
How do answers from history taking influence the assessment?
The answers provided during history taking help decide which assessments and tests to use.
What is the role of history taking in diagnosis?
It serves as a diagnostic factor and helps distinguish between different diagnoses.
How is dizziness described in a more specific manner?
Instead of using the term ‘dizzy,’ more specific symptoms and descriptions are used to accurately understand the patient’s condition.
Why should the term ‘dizzy’ be avoided in history taking?
The term ‘dizzy’ is very vague and non-specific, making it less useful for accurate diagnosis.
what are some examples of ways patients describe their symptoms?
Walking on cotton wool
Sinking into the floor
Eyes are playing catch up (image is moving)
Spinning
Disorientated and imbalance
Struggles to walk in the dark
Veering off to one side – Unable to walk in a straight line
Sensitive to light
Unable to look over my right/left shoulder
Extreme symptoms: BLACKOUTS (This should be referred)
What techniques should be used in history taking?
- Open-ended questions
- Accurate timeline
- Pay attention to off the cuff comments
- Be patient (symptoms can be difficult to describe)
- Summarize and confirm understanding
What key features should be included in history taking?(8)
- Onset: How long ago, any colds or accidents?
- Presenting features: Headaches, nausea
- Frequency: How often does it occur?
- Triggers: What causes it (e.g., looking up, rolling over in bed)?
- Duration: How long does it last (seconds, minutes)?
- Sensation: Type of sensation (spinning, swaying)
- Coinciding factors: Tinnitus, changes in hearing
- Medical conditions and medications
- (8)
What are some top tips for effective history taking?
- Write it down and use prompts
- Keep an accurate record
- Stay on topic and check understanding
- Identify contra-indications
- Have good knowledge of key vestibular conditions
is vestibular neuritis central or peripheral disorder?
Vestibular Neuritis is a peripheral vestibular disorder, not a central one, as it affects the vestibular nerve.
