Vestibular disorders

Question 1

Symptoms of vestibular dysfunction

Answer 1

Oscillopsia (illusion that environ. is moving)
Disequilibrium/imbalance
Vertigo, abnormal sense of mvmt, disorientation

Question 2

Dizziness definition

Answer 2

sensation of disturbed or impaired spatial orientation without a distorted sense of motion

Question 3

Vertigo definition

Answer 3

sensation of self motion when no self-motion is occurring

Question 4

presyncope definition

Answer 4

sensation of impending loss of consciousness

Question 5

syncope definition

Answer 5

transient loss of consciousness due to transient cerebral hypoperfusion

Question 6

Framework for approaching examination of acute dizziness/vertigo

Answer 6

TiTrATE approach
- timing
- triggers
- targeted exam
- test/PT treatment

Question 7

Timing

Answer 7

Acute vestibular syndrome: sudden and continuous dizziness lasting days to weeks

Episodic vestibular syndrome: intermittent dizziness lasting seconds, minutes, or hours

Chronic vestibular syndrome: longstanding (>3 mo) vestibular symptoms

Question 8

Triggers

Answer 8

trauma, toxin exposure, exertion, head motion/change in position

spontaneous (no trigger)

Question 9

Acute timing triggers and causes

Answer 9

Acute (>24 hrs)

Triggers: trauma, toxin exposure

Benign causes: vestibular neuritis

Serious causes: ischemic stroke of lateral BS, cerebellum, or inner ear

Question 10

Episodic timing triggers and causes

Answer 10

Triggers: head motion, change in body position, exertion

Benign causes: BPPV, orthostatic hypotension, vestibular migraine

Serious causes: TIA, posterior fossa mass lesion, cardiac arrhythmia

Question 11

Peripheral causes

Answer 11

Vestibular neuritis
Labyrinth neuritis (effects hearing)
BPPV

Question 12

Central causes

Answer 12

Stroke
TIA
MS
Vestibular migraine

Question 13

Central findings

Answer 13

• Direction changing nystagmus
• Vertical and purely torsional fixation nystagmus
• Vertical refixation skew deviation
• negative bilateral head impulse test

Question 14

I.N.F.A.R.C.T.

Answer 14

In a patient with acute, spontaneous dizziness, INFARCT points to CENTRAL issue

• Impulse negative bilaterally
• Fast-phase alternating nystagmus
• Refixation during cover test (skew)

Question 15

Nystagmus

Answer 15

involuntary rhythmic oscillation of the eye; named for direction of fast-phase of mvmt

• spontaneous
• gaze evoked

Smooth pursuit, saccades

Question 16

Test of skew

Answer 16

Cross-cover test
Looking for vertical refixation of eye
Skew deviation points to central lesion

Question 17

Head impulse test

Answer 17

Tests VOR integrity

Normal: eyes stay on nose w/ thrust

Abnormal: corrective saccade (eye-refixation) w/ thrust

Positive test = peripheral finding

Question 18

Other exam red flags

Answer 18

New postural/gait instability
5 D’s
Sudden, severe, or sustained pain (posterior neck)
CN signs
Sensory changes
Excessive vomiting

Question 19

Common peripheral pathologies

Answer 19

Benign paroxysmal positional vertigo (BPPV)
- most common cause of vertigo

Vestibular hypofunction

Less common:
- acoustic neuroma
- meniere’s disease
- perilymph fistula

Question 20

Vestibular hypofunction causes

Answer 20

Damage to inner ear or CN VIII

Cause:
- vestibular neuritis
- labyrinthitis

Ototoxic medication
- gentamycin
- chemotherapy agents, cisplatins

Question 21

Vestibular hypofunction findings

Answer 21

• Vertigo for hours/days (acute)
• chronic phase may present vertigo only w/ head mvmt
• nausea/vomiting
• imbalance
• nystagmus (beats towards healthy ear)
• positive head impulse test
• no central signs

Question 22

Vestibular hypofunction treatment

Answer 22

Medical management
- anti-vertigo (meclizine)
- anti-nausea (zofran)

Vestibular rehabilitation
- See CPG
- gaze stabilization

Question 23

Peripheral neoplasms acoustic neuroma

Answer 23

Schwannoma, small, encapsulated, slow growing

Puts pressure on facial n.

Can be seen on MRI

Surgical removal or radiosurgery

Question 24

Endolymphatic hydrops Meniere’s disease

Answer 24

Acute episodes: 30 min to 24 hr
Recovery w/in 72 hours

Progressive hearing/vestibular impairments

Endolymphatic hydrops
- malabsorption of endolymph in the duct and sac

Surgery or ablation

Question 25

Superior canal dehiscence (SCD)

Answer 25

Creates a window through the bone Can be seen on CT Features: - vertigo and oscillopsia induced by loud noises - autophony - surgical repair is possible

Question 26

Persistent postural-perceptual dizziness (PPPD)

Answer 26

Central, functional neurologic disorder BPPV can become PPPD

Question 27

PPPD diagnostic criteria

Answer 27

One or more symptoms of dizziness, unsteadiness, or nonspinning vertigo are present on most days for 3 mo or more Persistent symptoms occur without specific provocation, but are exacerbated by - upright posture - active/passive motion w/o regard to direction or position - exposure to moving visual stimuli or complex visual patterns Disorder is precipitated by conditions that causes vertigo, unsteadiness, dizziness, or problems w/ balance including acute, episodic, or chronic vestibular syndromes, other neurologic or medical illnesses or psychologic distress

Question 28

Pathophysiological mechanism of PPPD

Answer 28

Precipitants: - vestibular crisis - medical event - acute psychological distress Acute adaptation - visual-somatosensory dependence - high-risk postural control strategies - environmental vigilance No recovery in PPPD

Question 29

PPPD presentation

Answer 29

Persistent hypersensitivity to vision - sensitivity to busy/moving env. - difficulty w/ visually demanding tasks Perceived somatizations - head fullness, lightheadedness, "walking in fun house" - sense of unsteadiness

Question 30

PPPD treatment

Answer 30

3-pronged approach - medication (SSRIs, SNRIs) - PT w/ strong education component - Cognitive behavioral therapy

Question 31

Mal de debarquement syndrome (MdDS)

Answer 31

Perception of motion when stationary and eyes are open "getting off the boat" syndrome Occurs after prolonged exposure to motion (cruise) difficulty adapting back to stable env.