vestib - diff dx Flashcards
what is the importance of asking good subjective Qs
help provide important diff dx info
- 80% chance that your diff dx is correct
what are the main subjective questions to ask
primary complaint
h/o of HAs, migraines, GAD
-> can contribute to vertigo sx
what can vertigo be attributed to
vestib system dysfunction
what can lightheaded be attributed to
hypotension
(ie orthostasis, arrhythmia, syncopal episodes)
what is a good strategy to get pts to clarify their sx
tell me what you are feeling w/o using the word dizzy
what can disequilibrium be attributed to
imbalance stemming from multiple problems
(ie visual loss, neuropathy)
- all contribute to postural control
what can oscillopia be attributed to
spontaneous nystagmus or severe, bilateral hypofunction
- can be uni, more commonly (B)
what is oscillopsia
everything is moving as you moving
- everything is bouncing
what can motion sensitivity be attributed to
migraine, BPPV
what are diff dx for sx of floating, swimming, rocking, spinning inside of head
depression
anxiety
somatoform disorders
mild TBI/concussion
cervical spine dysfunction
what are possible dx for a sx duration of seconds
BPPV
perilymphatic fistula
what are possible dx for a sx duration of minutes
migraine
TIA
panic attack
what are possible dx for a sx duration of hours
migraine
meniere’s
hypotension
what are possible dx for a sx duration of days
neuritis
CVA
possibly a migraine
what are possible dx for a sudden onset of sx
neuritis/labyrinthitis -> UVH
BPPV
meniere’s
stroke
what are possible dx for a gradual onset of sx
acoustic neuroma
stroke (slow bleed)
what are possible dx for an onset of sx preceded by infection
labyrinthitis/neuritis
- ear or sinus infections can travel to labyrinth or CN 8
what are possible dx for an onset of sx preceded by trauma
cervicogenic dizziness
BPPV (knocked crystal into SCC)
post-concussive syndrome
what are possible dx for an onset of sx d/t a change in meds
SE of meds
- ototoxicity from aminoglycoside antibiotics (toxic to otoliths -> BVH sx)
what are possible dx for a positional dependent trigger
BPPV (moving SCCs)
vertebrobasilar insufficiency
UVH (impacts VOR)
what is the path behind vertebrobasilar insufficiency vertigo
post aspect of circulation
- if tilt head posterior can cause occlusion of vertebrobasilar a.
what are possible dx for a change in pressure (associated w sneezing/coughing) trigger
perilymphatic fistula
- fistula in peripheral vestib system causing pressure changes
what are possible dx for a dark room trigger and why
bilateral hypofunction
in dark room take vision away, now don’t have vision or vestib system to help w balance
what are examples of activities pts may avoid since sx onset
putting head back - VBI
turning head - BPPV
what are possible dx for an associated sx such as hearing loss
labyrinthitis
- how to diff from neuritis
acoustic neuroma
- tumor growing on CN 8
AICA infarct
meniere’s
what are possible dx for an associated sx such as n/v
UVH - gaze instability
BPPV
brainstem involvement
what are possible dx for an associated sx such as blurriness w head mvmt
UVH (VOR)
what are possible dx for an associated sx such as HA
migraine of CNS
what are possible dx for an associated sx such as ear fullness/pain, tinnitis
meniere’s
what are possible dx for an associated sx such as photo- / phonophobia
migraine
what are follow up questions to ask to sus out possible dx for an associated sx such as unsteadiness/falls
with what activities?
- figure out what position their head is in
what are possible dx for an associated sx such as 5 neuro D’s
Dizziness
Diplopia
Dysarthria
Dysphagia
Drop attack
CNS dysfunction!
what is one of the first things you want to figure out if someone is presenting w s/sx of vestib path
r/o stroke
r/o CNS path
what is the importance of the “HINTS” exam
dx stroke more sensitively than early MRI
what are the criteria of HINTS exam (+) for central path
HI = Head Impulse is (-) or normal, no corrective saccad
N = nystagmus changes direction or is vertical/torsional
TS = Test of Skew deviation that has vertical saccadic correction
what do you do w the info from the criteria of the HINTS exam
if any of the 3 are present or (+), indicative of CNS path and need imaging to r/o stroke
- if all present pretty confident that it is a stroke or CNS path
what are the criteria of HINTS exam (+) for peripheral path
HI = Head Impulse is (+) or abnormal, corrective saccade to midline w rotation
N = nystagmus non-direction changing, horizontal
TS = no skew deviation
what is the Test of Skew deviation and what result would indicate central path
cover test of one eyeball
- if uncover eye and it is in malaligned and you see vertical realignment as eye jumps back
what is the ocular tilt response
triad of sx indicating dysfunction:
1. ocular tilt
- head rotated toward affected side
- skew deviation
- vertical misalignment of eyes - ocular torsion
- eyes will not rotate to stay vertical in orbit in presence of ocular tilt
what are sx of vascular pathology involvement
vertigo
n/v
imbalance
nystagmus
intolerance to motion
what is are 2 considerations with vascular path
CNS path can be vascular in nature
infarct or hemorrhage can cause sx similar to those seen w peripheral vestib path
what are the 3 main points to help differentiate b/w central and peripheral vestib dysfunction
pt hx and sx complaint
oculomotor / vestib exam
postural control and gait
how can you differentiate between BPPV and VBI
VBI seated test:
- lean upper trunk forward, head turned 45deg to test side and ext
- look for sx as can occlude vessel
(VBI brought on by position of cspine regardless of head position relative to gravity)
what is an important consideration with VBI seated testing
little efficacy
- perform test anyway bc of serious nature of a (+) VBI test
