Vestibular Flashcards
Someone comes in for dizziness. They feel spinning, rocking, swaying, falling when moving. What is the possible diagnosis?
Vertigo: illusion of movement
Someone comes in for dizziness and they feel off balance when moving. “Unsteady, wobbly, drunk, tilted”
What could it be
Movement related vestibular problem: DISEQUILIBRIUM
Someone comes in for dizziness. They feel foggy-headed, heavy-headed, motion-sickness, light headed when moving.
Movement related vestibular problem
(Could be cardiovascular in nature, so rule out)
Someone comes in for light headedness, feeling faint, and tunnel vision. What could their dizziness be?
Possibly cardiovascular in nature. RULE IN/OUT
Someone comes in for dizziness, stating they feel “floating, swimming, rocking” sensations. What could it be
Anxiety
Someone comes in with diplopia or oscillopsia. What could it be?
Visual issue
(oscillopsia –> jumping eyes, possibly bilateral vestibular hypofunction and impaired VOR)
Symptom: dysequilibrium, imbalance/unsteady while standing or walking
Mechanism:
Mechanism:
loss of Vestibulospinal, proprioceptive, visual, or motor function
Joint pain/instability
Psychological factors
Someone feels lightheaded or like they are going to faint (presyncope)
What is mechanism:
Cardiovascular, decreased BF to brain
Symptom: sense of rocking/swaying, like on a ship
Mechanism:
Symptom: Mal de Debarquement
Mechanism: vestibular system adapts to continuous passive motion and has not yet adapted to stable environment
Or could be anxiety
Someone feels motion sickness.
Mechanism:
Visual-vestibular mismatch
Someone has nausea and vomiting.
Mechanism:
Stimulation of medulla
Symptom: someone sees the world jumping (oscillopsia), illusion of visual motion
Mechanism:
Head induced: severe, bilateral loss of VOR (vestibulo-ocular reflex)
Someone feels like floating, swimming, rocking, spinning, but not reproducible with movement
Mechanism:
Could be anxiety, depression, soma to form disorders
Someone has vertical diplopia (double vision up and down)
Mechanism:
Skew eye deviation
Symptom: vertigo (rotation, linear, tilt)
Mechanism:
Imbalance of tonic neural activity to vestibular cerebral cortex
Tempo of:
Vestibular neuritis
Or
Labyrinthitis
Sudden onset, ACUTE
Duration: lasting days
Frequency: single event
Tempo of BPPV
Short spells (seconds to 1 minute)
Frequency: recurring
Tempo of bilateral hypofunction
Gradual onset over months/years
Frequency: constant/chronic
TEMPO: Menieres Disease
Or
Vestibular migraine
Duration: sudden/acute onset, lasts hours-days
Frequency: recurring spells
TEMPO of Wallenberg infarct
Sudden onset/acute
Lasts hours-days
Single event
TEMPO of orthostatic hypotension
Short spells (seconds-minutes)
Recurring
MDDS or PPPD tempo
Constant
Fluctuating severity
Chronic
Aggs/eases for BPPV
AGGS: positional (lying, sitting up, turning, bending forward)
Eases: hold still, time
AGGS/EASES for gaze-instability
Aggs: head mvmt, visual-vestibular mismatch
Eases: hold still, CLOSE EYES
AGGS/EASES for imbalance
Aggs: walking, darkness, unstable surfaces, standing up
Eases: sitting, supporting self with arms
AGGS/EASES for vestibular neuritis
Aggs: spontaneous, exacerbated by head movement
Eases: holding still, closing eyes, medication
AGGS/EASES for vestibular migraine or Ménière’s disease
Aggs: spontaneous, exacerbated by head movement and common triggers
Eases: hold still, close eyes, meds
AGGS/EASES for CVA/TIA
Aggs: spontaneous, no eases
Aggs/eases for OTHN
Aggs: positional, standing, sitting up
Eases: sitting, time
Does mal de debarquement get better with holding still?
Not really. Exception to movement related vestibular disorders
Aggs/eases for ischemia
Aggs: cardiovascular strain, exercise
Better: rest
Components of vestibular screen
- Subjective report/systems review
- Observe for spontaneous nystagmus
- Observe for oculomotor issues (skew eye deviation, ocular tilt reaction)
- Oculomotor testing (smooth pursuit, saccades)
- VOR tests: HSNT, HTT, DVA
- HINTS exam
- Postural control/balance screen
- BPPV test: only if nystagmus and vertigo are provoked with positional head movement change
Peripheral vs central spontaneous nystagmus:
Peripheral: fixation decreases nystagmus
Central: no effect with fixation, and direction-changing nystagmus
When testing for smooth pursuits and saccades, what does it mean when these are abnormal?
Saccades: high sensitivity for CNS involvement
Looking for central involvement
If VOR is abnormal, what test is used to check and what will you see?
What does it indicate?
Test: head thrust test (HTT)
Abnormal result: corrective saccade
Indicates: hypofunction (unilateral vestibular issue)
PERIPHERAL VESTIBULAR PROBLEM
What is an indication of a stroke/central vertigo with HINTS testing?
HIT: normal, intact VOR
N: Vertical, rotatory, or horizontal bidirectional nystagmus (direction changing)
TS: test of skew is POSITIVE
What are results of peripheral vertigo (vestibular neuritis) with a HINTS exam?
HIT: positive
Nystagmus: unidirectional (none or horizontal)
TS: negative skew
If patient takes more than one step back/falls back like a log during retropulsion testing, what does this indicate?
Basal ganglia problems (maybe Parkinson’s?)
Components of a vestibular screen: balance/postural control
Gait + head turns
Rhomberg: EO/EC, firm/foam
Tandem
Fukuda (not clinically useful)
Retropulsion testing
What are the 5Ds and 3 Ns of vertebral artery insufficiency
- Dizziness
- Diplopia
- Dysarthria
- Dysphagia
- Drop attacks
- Nausea
- Nystagmus
- Numb/tingling face
BPPV:
Dix Hallpike testing for canalithiasis looks like
Duration: latent onset of vertigo/nystagmus
Intensify, then subside (episodic)
Lasts few seconds-less than 1 minute
BPPV:
Dix Hallpike testing for cupulolithiasis looks like:
Duration: immediate onset of vertigo/nystagmus
Intensity remains constant (posterior canal) as long as that canal is provoked or varies (horizontal canal) depending on side of involvement
Lasts as long as head is in provoking position
which Law: gaze towards fast phase increases intensity of nystagmus
Alexander’s law (Peripheral Nystagmus)
