Test 3 Flashcards
what are the ddx for dizziness
- Vertigo
- Acute severe vertigo
- Recurrent positional vertigo
- Recurrent spontaneous vertigo
- Syncope or presyncope
- Arrhythmia
- Valvular disease
- Acute coronary syndrome
- Brugada syndrome
- Wolff-Parkinson-White syndrome
- Carbon monoxide poisoning
- Orthostasis
- Subarachnoid hemorrhage
- Transient ischemic attack
- Stroke
- Orthostatic hypotension/POTS
- Dehydration
- Disequilibrium
- Peripheral neuropathy
- Parkinson’s
- B12 deficiency
- Cataracts
- Lyme
- Lightheadedness
- Hypoglycemia
- Anxiety
- Encephalopathy
- Medication side effects
shuffling gait, bradykinesia, and wide based ataxic turns
parkinson’s disease
unsteady gait
peripheral neuropathy
ataxic gait
cerebellar disorder
HINTS
Head Impulse, Nystagmus, Test of skew
what is spontaneous nystagmus
movement of the eyes without a cognitive, visual or vestibular stimulus, occurs consistently with fixed central gaze position stationary, upright, and neutral positions
Gaze Nystagmus
holding off center gaze produces eye movement
when assesing nystagmus what do you note?
unilateral or bilateral
horizontal, vertical or rotational
suppression
Vestibular-ocular reflex, Head-Impulse (or head thrust) test
Thrust patients head 20-30 degrees while the patient fixates on the examiner’s nose
unidirectional, horizonatal Nystagmus
peripheral vertigo
bidirectional, rotational or pure vertical Nystagmus
central vertigo
horizontal with the fast phase beating away from the hypoactive labyrinth
Peripheral vertigos
Down beat, torsional or true vertical nystagmus
central vertigo
which nystagmus can be suppressed by visal fixation?
Peripheral nystagmus
catch-up saccade to re-fixate on the target (your nose) when thrust is in the direction of the lesion (head thrust)
peripheral vertigo
Test of Skew
assessed by asking the patient to look straight ahead, then cover and uncover each eye
test of skew +
Vertical deviation of the covered eye after uncovering indicative of central vertigo
Dix-Hallpike, Nylan-Barany maneuvers, or George’s test
Observe patient at rest, test extraocular motions (EOM). Rotate and extend head, lay patient down and hold position for 30 second or patient tolerance
Dix-Hallpike, Nylan-Barany maneuvers, or George’s test + means
positional vertigos
Romberg Tests
The patient is asked to remove his shoes and stand with his two feet together. The arms are held next to the body or crossed in front of the body.
The clinician asks the patient to first stand quietly with eyes open, and subsequently with eyes closed. The patient tries to maintain his balance. For safety, it is essential that the observer stand close to the patient to prevent potential injury if the patient were to fall. When the patients closes his eyes, he should not orient himself by light, sense or sound, as this could influence the test result and cause a false positive outcome.
The Romberg test is scored by counting the seconds the patient is able to stand with eyes closed.
Sharpened Romberg Tests
he patient has to place his feet in heel-to-toe position, with one foot directly in front of the other.
the assessment is performed first with eyes open and then with eyes closed.
The patient crosses his arms over his chest, and the open palm of the hand lies on the opposite shoulder. The patient also distributes his weight over both his feet and holds his chin parallel with the floor
Romberg and Sharpened Romberg Tests + eyes open
cerebellar disorder
Romberg and Sharpened Romberg Tests + eye closed
peripheral neuropathy or vestibular disorder
Past pointing
ask patient to touch your fingers with eyes open, and then eyes closed
Past Pointing Dysmetria or dysdiadochokinesia
cerebellar lesion
fistula test
insufflation
Fistula Test +
opening (perilymphatic fistula) between the TM and the vestibular apparatus, the change in aural pressure will cause symptoms and or nystagmus
Hennebert’s sign
pushing on tragus and external auditory meatus
Hennebert’s sign +
few beats of horizontal nystagmus seen under Frenzel glasses without clinical evidence of middle ear or mastoid disease
indicates congenital syphilis and Meniere disease
Caloric Testing
a specialist has patient is sitting back at 30º and cold water (ice cubes in water for 10 minutes) is instilled into ears
Caloric Testing +
iced water on the damaged side either does not cause nystagmus, or has no effect on any spontaneous nystagmus indicating a peripheral lesion
Headshake test
Shake head for 20 seconds at 2 Hz with eyes closed then inspect eyes for nystagmus
unilateral nystagmus in the horizontal plane (Headshake test)
peripheral vertigo
vertical nystagmus (headshake test)
central vertigo
Videonystagmography (VNG)
measures the movements of the eyes directly through infrared cameras
can decipher between a unilateral (one ear) and bilateral (both ears) vestibular loss
VNG procedure
Ocular Mobility
Optokinetic Nystagmus
Positional Nystagmus
Caloric Testing
Ocular Mobility part of VNG
The patient is asked to follow objects that jump from place to place, stand still, or move smoothly
slowness or inaccuracies in following visual targets (ocular mobility)
central or neurological problem, or possibly a problem in the pathway connecting the vestibular system to the brain
Optokinetic Nystagmus
The patient views a large, continuously moving visual image to see if their eyes can appropriately track these movements
Optokinetic Nystagmus + any slowness or inaccuracies in following visual targets
central or neurological problem, or possibly a problem in the pathway connecting the vestibular system to the brain
Positional Nystagmus
technician will move the patients head and body into various positions to make sure that there are no inappropriate eye movements
Aconite
something bad happens/shock/trauma causing the person to become dissociative, excessive excitability in nervous and vascular system,
lots of anxiety, sudden, fearful
one cheek red, one pale
anxiety with heart sx
sensitive to outside stress
bright red
worse cold
hot
Apis
busy bee, like having task/jobs, like to organize, jealous
protective and easily turn into an enemy/annoyed
swollen, tight, bursting, dusky redness
drop things
worse from suppressed eruptions, hearing bad news, shock
hot
right-sided
Arsenicum album
anxious, restless, proper, tense, worried, depressed, perfectionistic
can’t be easily consoled, hypochondriac
restlessness exhausts them
suicidal ideation but fear of death
cold want heat
disgusting discharge
right-sided
Belladona
intense, delirious, pulsing
deep red, hot, and dry
sudden onset of physical or emotional sx
right-sided
twitching/jerking
dilated pupils
Phosphorous
open to people, infections,
bubbly
sensitive to other emotions
spacey
discharge easily pours out of them
gas, bloating
left-sided
anxiety about health
bright red blood
Vestibular evoked myogenic potential
neurophysiological technique used to determine the function of the utricle and saccule of the inner ear
obliterates VEMP’s
conductive hearing loss
does little or nothing to VEMP’s
sensorineural hearing loss
“Tullio” effect
Sound-induced vertigo; disequilibrium or dizziness, nystagmus and oscillopsia triggered by sounds
Peripheral vertigo
dysfunction somewhere in the middle or inner ear, affecting the vestibular apparatus
Spontaneous nystagmus is unidirectional and horizontal
moderate to severe
Central vertigo
dysfunction in the CNS brain stem or cerebellum
vertigo mild to severe
N/V less severe
associated with weakness, dysarthria, vision changes, paresthesia, altered mental status, ataxia or other motor/sensory
DDX for central vertigo
drugs
stroke
Vertebrobasilar insufficiency,
Multiple Sclerosis
Tumors near the cerebellopontine angle (CPA) angle
Wernicke encephalopathy
encephalitis, meningitis
TBI
What drugs/substances cause vertigo
alcohol
Barbiturate
seizure med: phenobarbital Dilantin, Lamictal and Depokote
Head impulse test indicating peripheral
corrective saccade
head impulse test indicating central
normal exam
head impulse test indicating central
normal exam
Suppression of nystagmus with visual fixation
peripheral
minimal or some suppression of nystagmus with visual fixation
central
smooth pursuit intact
peripheral
smooth pursuit broken
central
Dix-hallpike showing latency, adaptability, fatigability.
peripheral
Dix-hallpike showing no latency, no adaptability, no fatigability.
central
diminished hearing, tinnitus indicates which vertigo
peripheral
normal hearing indicates which vertigo
central
abnormal caloric testing indicates which vertigo
peipheral
normal caloric test indicates which vertigo
central
nystagmus and vertigo after a loud noise (Tulio’s phenomena) indicates which vertigo
peripheral
no nystagmus and vertigo after a loud noise (Tulio’s phenomena) indicates which vertigo
central
Vestibular neuritis cause
hypoactive vestibular apparatus due to viral infection (URI)
Vestibular neuritis sx
bell’s palsy
sudden severe, frequent to constant, spontaneous, and worse with movement vertigo/imbalance with N/V
vestibular neuritis PE
spontaneous horizontal-torsional nystagmus beating away from the lesion side
head impulse test +
caloric test +
decreased VEMPs
unsteadiness with a falling tendency toward the lesion side
vestibular neruritis Tx/management
resolve days to weeks
supportive care
IV hydration
Labyrinthitis cause
inflammation of the labyrinth
Autoimmune cause bilateral labyrinthitis
Ototoxic drugs (gentamicin, streptomycin or neomycin, phenytoin (Dilantin), antihypertensive, diuretics, nitroglycerine, quinine, salicylates, sedative/hypnotics)), TB treatment
Herpes viruses, influenza, measles, rubella, mumps, polio, hepatitis, and Epstein-Barr.
Herpes zoster oticus cause severe labyrinthitis
AOM or OME
Viral labyrinthitis Sx
sudden, unliteral vertigo serve and incapacitating with N/V
hearing loss
Viral labyrinthitis PE
spontaneous nystagmus away from the affected side
absent caloric responses in the affected ear
head impulse test is positive
hearing loss is usually mild to moderate and typically evident in the higher frequencies (>2000 Hz),
Serous labyrinthitis cause
of chronic, untreated middle ear infections (serous otitis media aka OME)
Serous labyrinthitis sx
unliteral vertigo with N/V
hearing loss
CNS stroke Sx
focal weakness
slurred speech
Rothrock criteria
Patient > 60 years, new onset focal neurologic deficit, headache with vomiting, or altered mental status
RF for CNS stroke
older age, hypertension, and diabetes
CNS stroke PE
head impulse test will be normal
Benign Paroxysmal Positional Vertigo sx
Brief episodes (1 minute) of vertigo that are triggered by positional changes
Benign Paroxysmal Positional Vertigo cause
Development of otolith (calcium carbonate precipitates in endolymph) roll across hairs when head moves and sends aberrant signals to brain causing vertigo
secondary to head trauma, dental surgery, middle ear infection (AOM), and Labyrinthitis
Benign Paroxysmal Positional Vertigo PE
Dix-Hallpike + a transient burst of upbeat nystagmus is seen, Nystagmus fatigues on repeat examination
types of BPPV
anterior canal BPPV (AC-BPPV) (3rd)
posterior canal BPPV (PC-BPPV) (most common)
horizontal canal BPPV (HC-BPPV) (2nd)
Treatment for BPPV
Epley maneuvers
Horizontal SCC BPPV
experience severe vertigo when lying supine and rotating the head
Anterior (SCC) BPPV TX/DX
Dix-Hallpike
Variants of the Dix-Hallpike maneuver may also treat anterior canal BPPV
Central Positional Vertigo cause
lesion in the cerebellum or brainstem
Central Positional Vertigo PE
downbeat or pure torsional nystagmus on Dix-Hallpike
Meniere disease cause
Blockage of endolymphatic sac or duct
autoimmune mechanisms
genetic predisposition
Herpes (Varicella zoster, HSV), CMV
Vascular etiology
edema within the endolymphatic space
Meniere disease sx
episodic attacks (2-24 hrs. between episodes) of vertigo that is severe too violent with nausea and vomiting
aural fullness worse w/ downward fluctuations in hearing
tinnitus can be loud and roaring
fluctuating sensorineural hearing loss often affecting the lower frequencies
unilateral
Meniere disease onset
affects middle-aged women,
Meniere disease PE
head impulse test will lateralize vestibular dysfunction to the symptomatic ear.
audiology: low frequency or combined low- and high-frequency sensory loss with normal hearing in the mid frequencies
- Two or more spontaneous episodes of vertigo with each lasting 20 minutes to 12 hours
- Audiometrically documented low- to medium- frequency sensorineural hearing loss in one ear, defining and locating to the affected ear on in at least one instance prior, during or after one of the episodes of vertigo
- Fluctuating aural symptoms (fullness, hearing, tinnitus) located in the affected ear
- Not better accounted for by any other vestibular diagnosis
Meniere disease dx
Transient Ischemic Attack SX
sudden and short episodes of vertigo and hearing loss that get worse in a crescendo pattern
focal neurologic deficits
Transient Ischemic Attack RF
hypertension, diabetes, hyperlipidemia
Bilateral vestibular failure cause
aminoglycoside toxicity Gentamicin and streptomycin
Acoustic Neuroma SX
Slowly progressive unilateral hearing loss in high frequencies
50% vertigo
tinnitus
vague dizziness or vertigo
facial weakness later in disease
Acoustic Neuroma DX
Refer to ENT for audiology (retrocochlear deficit pattern)
Auditory brainstem response (ABR)
MRI of the interior auditory canal with gadolinium contrast
Perilymphatic Fistula cause
Breach between the middle and inner ear. Secondary to trauma from a direct blow or sudden barotraumas, occasionally heavy weight bearing or straining.
Perilymphatic Fistula SX
symptoms worse by insufflation
vertigo and mixed sensorineural hearing loss
Superior canal dehiscence cause
bone overlying the superior aspect of the superior semicircular canal becomes thin or even absent, thereby allowing pressure to be transmitted to the inner ear
secondary to trauma, or barotrauma
Superior canal dehiscence sx
Coughing, sneezing, and loud noises (Tulllio phenomenon) can provoke vertigo
oscillopsia (objects in the visual field appear to oscillate) and autophony
hyperacusis
Superior canal dehiscence dx
clicked vestibular evoked myogenic potential c(VEMP)
MRI or high-resolution CT of the temporal bone.
Migrainous Vertigo sx
Episodic moderate dizziness
stimuli such as light, sound, or motion, can trigger or aggravate symptoms
Migrainous Vertigo DX
based on the symptoms, degree, frequency, and duration of the vestibular episodes, a history of migraine, and the temporal association of migraine, ruling out what may be due to other reasons
The head impulse test will be normal
Neuhauser Criteria for Migrainous Vertigo
Episodic vestibular symptoms of at least moderate severity Vertigo; positional dizziness and head motion intolerance
Migraine according to the International Headache Criteria
One or more of the following features during at least two vertigo attacks
Migrainous headache
photophobia
phonophobia
migraine aura
Other diagnoses excluded by appropriate tests
Cervicogenic Vertigo sx
Vague dizziness
Cervicogenic Vertigo cause
triggered by somatosensory input (position sense) in the cervical joints from head and neck movement neck injury (whiplash),
Cervicogenic Vertigo TX
physical therapy and manipulation
Hearing loss PE
Webber
Rinne
whispered voice test
Webber
measures bone conduction
use 512 Hz tuning fork
Lateralize to bad ear = conductive hearing loss
Lateralizes to good ear = sensorineural hearing loss
Rinne
AC > BC = Normal
BC > AC= Conductive hearing loss
AC > BC, (both diminished)= Sensorineural hearing loss
pure tone audiology
test air conduction and bone conductio
Air conduction
measured with earphones and tests the entire auditory system.
mild hearing loss
26–40 dB, difficulty with faint or distant speech
moderate hearing loss
41–55 dB
moderate to severe hearing loss
56–70 dB, speech must be loud; difficulty with group conversation
severe hearing loss
71–90 dB, difficulty with loud speech; understands only shouted or amplified speech
profound hearling loss
91+ dB, may not understand amplified speech
Speech audiometry
measures the threshold that speech can be accurately heard
Tympanometry
measure of tympanic membrane mobility (Static admittance, or Compliance (TM mobility) and an indirect measure of middle ear pressure.
Electrocohleography
method for recording the electrical potentials of the cochlea
Auditory Brainstem Response
time taken for an impulse to get from the cochlea to the brainstem is measured.
Otosclerosis population
early 20s, 40-50s peak incidence, females, Caucasians,
Otosclerosis sx
Progressive conductive hearing loss, usually with preserved speech discrimination or sensorineural hearing loss with cochlear involvement
Otosclerosis PE/Dx
Carhart’s notch: A dip in bone conductive threshold at 2000 Hz. on audiometric testing
Schwartze’s sign: Pinkish/blue hue on promontory upon otoscopic examination
Tympanogram will indicate lower impedance (Type AS Stiff)
CT scan
Traumatic hearing loss cause
ears boxed, barotrauma, and explosions
Cholesteatomas sx
profound conductive hearing loss
recurrent vertigo
Sensorineural hearing loss
hearing loss for problems with the cochlea and problems with CN 8 or CNS
Sensorineural hearing loss cause
viral/bacterial: measles, syphilis, VRI, rubella, strep AOM infection
brain injury
granulomas, meningioma’s, and acoustic neuroma
metabolic/vascular: DM, hypothyroidism, hyperlipidemia, hypercholsterolemia
Ototoxicity: aspirin, quinine, aminoglycoside, erythromycin, loop diuretics, thiazide diuretics, platinum-based chemotherapeutics, carbon monoxide, nicotine, alcohol, heavy metals, interferon a
Sudden Sensorineural Hearing Loss
Defined as a loss > 30 dB in three contiguous frequencies in a period of < 3 days
Sudden Sensorineural Hearing Loss dx
Diagnosis of exclusion
audiology and refer to ENT
assess hearing loss with whispered voice test and tuning fork test
hearing loss the sound will lateralize to the “good” ear
Sudden Sensorineural Hearing Loss cause
viral: Mumps, measles, herpes zoster, Zika and infectious mononucleosis
vascular: partial or complete occlusion of the cochlear vasculature
membrane rupture: rupture of the delicate inner ear membrane and fistulae of the round and/or oval window due to pressures from within (cerebrospinal pressure) or without (middle ear pressure) suddenly increases causing breaks in the cochlear membrane
Sudden Sensorineural Hearing Loss management
Refer these patients to an ENT for audiology and work up.
Glucocorticoid therapy
Prebyacusis
age related hearing loss
Prebyacusis cause
Loss of hair cells at the organ of Corti, later loss of cochlear neurons, the stria vascularis degenerates and shrinks and the ossicles and tympanic membrane becomes more rigid
Prebyacusis sx
hearing loss is, most often symmetric and gradual in onset causing loss of the high frequencies
Prebyacusis RF
male sex
white race
family history
older
service/blue-collar occupation
exposure to loud noises
lower education level
cognitive impairment
smoking
high serum homocysteine levels
low folic acid intake
hypertension
diabetes
Otoacoustic Emissions
- distortion tones
- test only way up to the cochlea and not the brain
- background noise interfere
Auditory Brainstem Response Testing
goes up to the brain
background noise doesn’t interfere
Automated ABR
screening method used
35dBnHL click stimulus
Threshold ABR
introduce a louder click
determining hearing level in patients who cannot be tested using traditional method
Neurodiagnositc ABR
retro-cochlear pathology, MS
adults who have hearing loss that sounds distorted on one side
Behavioral Hearing testing
visual reinforcement audiology
conditional play audiometry
conventional audiometry
conventional audiometry
patient raises a hand, presses a button, or verbally indicates that they hear a sound
conditional play audiometry
put block in bucket when they hear the noise
visual reinforcement audiology
patient turns when a sound is played through a speaker, reinforced by showing a toy or video
Mild hearing loss tx
- communication strategies
- speak louder
- look at them when talking
- be in the same room
- reduce background noise
- slow down speech
- lighting
- Low-gain hearing aid
Moderate to Severe/Profound TX
- hearing aids
- listening systems
Profound hearing with unusable hearing tx
- cochlear implant
- manual communication
Vestibulo-ocular reflex
the sensory signals encoding head movements are transformed into motor commands that generate compensatory eye movements in the opposite direction of the head movement, thus ensuring stable vision
Vestibulo-spinal reflex
composed of several tracts that connect the vestibular nuclei to the muscles of the neck, trunk, and extremities
need cerebellum input to maintain smooth movement
provides necessary compensatory movement to maintain head position, maintain postural stability, and prevent falls
Vestibulocollic reflex
stabilize head while moving
RF for falling
older age
women have higher rate of fracture
males have higher rate of death
Caucasians
video nystagmography
test for positional vertigo
HSCC function
oculomotor
gaze
positional: supine, head and body positions
Dix-Hallpike
Calorics
video head-impulse testing
utricular and saccular function/symmetry
VOR and VSR
post-urography
standing balance function
rotational chair
HSCC function
minutes to seconds dizziness tx
canalith repositioning procedure
hours to days dizziness Tx
dietary changes, VBRT
Persistent postural-perceptual dizziness
chronic functional disorder presenting with the complaints of dizziness and unsteadiness
Persistent postural-perceptual dizziness dx
One or more symptoms of dizziness, unsteadiness or non-spinning vertigo on most days for at least 3months.
1. Symptoms last for prolonged (hours-long) periods of time, but may wax and wane in severity.
2. Symptoms need not be present continuously throughout the entire day.
B. Persistent symptoms occur without specific provocation, but are exacerbated by three factors: upright posture, active or passive motion without regard to direction or position, and exposure to moving visual stimuli or complex visual patterns.
C. The disorder is triggered by events that cause vertigo, unsteadiness, dizziness, or problems with balance, including acute, episodic or chronic vestibular syndromes, other neurological or medical illnesses, and psychological distress.
1. When triggered by an acute or episodic precipitant, symptoms settle into the pattern of criterion A as the precipitant resolves, but may occur intermittently at first, and then consolidate into a persistent course.
2. When triggered by a chronic precipitant, symptoms may develop slowly at first and worsen gradually.
D. Symptoms cause significant distress or functional impairment.
E. Symptoms are not better accounted for by another disease or disorder.
Persistent postural-perceptual dizziness TX
vertigo rehabilitation exercises and medication, with cognitive-behavioral therapy for associated psychological morbidity, and can lead to a good outcome
causes of tinnitus
hearing loss, cholesteatoma, meniere disease, vestibular schwannoma, meds, temporomandibular joint dysfunction, head or neck injury, cerumen removal, MS, spontaenous intracrainial hypotension, type I Chiari malformation, idiopathic intracranial hypertension, vestibular migraine, viral, bacterial, fungal, hyperlipdemia, DM, Vit B12 deficiency, patulous eustachian tube, arterial bruit, venous hum, arteriovenous malformation, vascular tumors, carotid atherosclerosis, dissection, tortuosity, paget disease, palatal myoclonous, idiopathic stapedial, tensor tympani muscle spasm
Dx of tinnitus
pure tone audiometry with assessment of air and bone conduction, speech discrimination testing, tympanometry, auditory brainstem response, contrast-enhanced MRI, electronystagmography, CT angiography, carotid doppler ultrasonography, neck computed tomography angiography, MRI angiography, MRI venography, lumbar puncture
