Vestibular Disorders PPT Flashcards
Symptoms of vestibular dysfunction:
1.) oscillopsia - the illusion that the environment is moving
2.) disequilibrium/imbalance
3.) vertigo, abnormal sense of movement, disorientation
dizziness can lead to increased rates of falling
Dizziness is more common in ____ compared to ____
females, males
2.7: 1
dizziness
sensation of disturbed or impaired spatial orientation without a distorted sense of motion
vertigo
sensation of self motion with no self motion actually occurring
presyncope
sensation of impending loss of consciousness
syncope
transient loss of consciousness due to transient cerebral hypoperfusion
unsteadiness
feeling of being unstable while seated, standing, or walking
What is the name of the approach for examining acute dizziness or vertigo?
TiTrATE approach
TIMING
-acute vestibular syndrome: sudden and continuous dizziness lasting days to weeks
-episodic vestibular syndrome: intermittent dizziness lasting seconds, minutes, or hours
-chronic vestibular syndrome: lasting > 3 months vestibular symptoms
TRIGGERS
-trauma, toxin exposure, exertion, head motion/change in position
-spontaneous (no trigger)
TARGETED EXAM
TEST/PT TREATMENT (which may be refer)
What are some triggers and benign causes of acute vestibular disorders?
TRIGGERS: trauma, toxin exposure
CAUSES: vestibular neuritis- inflamed vestibulocochlear nerve
What are some triggers and benign causes of episodic vestibular disorders?
TRIGGER: head motion, change in body position, exertion
BENIGN CAUSE: BPPV, orthostatic hypotension, vestibular migraine
Serious causes of acute and episodic vestibular disorders
ACUTE
-ischemic stroke of the lateral brainstem, cerebellum, or inner ear
EPISODIC
-TIA, posterior fossa mass lesion, cardiac arrythmia
What is a common exam to perform to differentiate peripheral vs central vestibular disorder cause?
HINTS PLUS
HINTS PLUS exam components
Head impulse test
Nystagmus type
Test of skew deviation
Plus - acute, moderate-severe hearing loss associated with vertigo
** rule out central cause of symptoms
ORDER OF EXAM:
-screening for hearing loss in subjective
-nystagmus and test of skew
-head impulse test ** provocative test
Nystagmus and Oculomotor examination
involuntary rhythmic oscillation of the eye; named for direction of fast-phase of movement
TYPES
-unilateral nystagmus- peripheral sign
-spontaneous
-gaze evoked -CENTRAL
—> direction changing: central (R when turn R and L when turn L)
—> vertical and purely torsional fixation nystagmus: central
EXAM
-look for nystagmus during oculomotor exam —> smooth pursuit, saccades
Test of skew
cross cover test
-switch from covering left eye to covering right eye
CENTRAL FINDING:
-vertical re-fixation of the eye (slippage)
-looking for a vertical up/down drop
NORMAL: eye stays glued on examiner’s nose without any correction seen
head impulse test
-tests the integrity of the VOR and CN VIII
-tuck chin 30 deg to test horizontal canal
NORMAL:
-eye stays on the examiner’s nose with a head impulse
ABNORMAL:
-corrective saccade observed with the head impulse
-PERIPHERAL finding with abnormal test
*name with the side you thrust to–> impaired L inner ear with abnormal thrust to the left
Acronym used to help with identifying a central issue:
INFARCT
head impulse test - impulse negative bilaterally
nystagmus type - fast-phase alternating (direction changing)
test of skew - refixation during cover test
What test should you also perform if you are concerned with vertebral artery dysfunction?
5 Ds
dysphagia, dysphonia, dysarthria, dysmetria, diplopia
what are two common peripheral pathologies that can be seen in clininc?
MOST COMMON
-BPPV: most common cause of vertigo
-vestibular hypofunction
LESS COMMON
-acoustic neuroma
-Meniere’s Disease
-Perilymph fistula
Characteristics of vestibular hypofunction:
-damage to the inner ear or CN VIII
CAUSED BY:
-vestibular neuritis –> inflammation of CN VIII
-labyrinthitis
MEDS that are Ototoxic:
-Gentamycin - antibiotic
-some chemotherapy agents- cisplatins
SIGNS/SYMPTOMS:
-vertigo for hours/days (in acute phase)
-vertigo may only be with head motion/movement in chronic phase
-N & V
-imbalance
-nystagmus unilateral (peripheral finding) —> beats toward the healthy ear
-positive HIT
-NO central signs
-one side has a VOR that is dampened compared to the other side
Treatment for vestibular hypofunction:
MEDS
-antivertigo meds: Meclizine
-anti-nausea meds: Zofran
REHAB
-CPG
-gaze stabilization exercises
Acoustic neuroma characteristics:
-peripheral neoplasm
-usually a schwannoma
-usually small, encapsulated, and slow growing
-can be seen on MRI
-facial rehab may be needed because the CN VII also travels through the internal acoustic meatus
-TREATMENT: gaze stabilization and balance –> with good prognosis
-SURGERY - removal or radiosurgery may be indicated
Meniere’s Disease Charactertistics:
CAUSE: endolymphatic hydrops, malabsorption of endolymph in the duct and sac
“A floor-warping, ceiling-spinning, brain-churning,
think-you’re-gonna-die-and-afraid-you-might-not,
hangover.”
EPISODES: acute, 30 mini- 24 hours –> usually recover within 72 hours
-SYMPTOMS:
-progressive hearing/vestibular impairments
-surgery or ablation possible
Superior Canal Dehiscence characteristics
-creates a window through the bone;
SCDS is a rare condition caused by an abnormal thinness or incomplete closure of one of the bony canals in the inner ear
-can be seen on a CT scan
FEATURES:
-vertigo and oscillopsia induced by loud noises
-autophony (hearing bodily sounds)
-surgical repair is possible
Central vestibular disorders discussed in class:
-PPPD
-MdDS- mal de debarquement syndrome
PPPD- persistent postural-perceptual dizziness
- a functional neurologic disorder, treatable
-constitutes 15-20% of the diagnoses in tertiary balance centers
-AGE: mid 40s
-GENDER: female preponderance
-INCIDENCE: after acute or episodic vestibular episode about 25% at 3-12 months follow up
SIGNS:
-one or more symptoms of dizziness, unsteadiness, or non-spinning vertigo are present on most days for 3 months or more
-persistent symptoms are exacerbated by: upright posture, active or passive motion without regard to direction or position, exposure to moving visual stimuli or complex visual patterns, difficulty with busy/moving enviro
-precipitated by conditions that cause vertigo, unsteadiness, dizziness, or problems with balance including vestibular syndromes, other neurologic or medical illnesses, or psych distress
-feel head fullness, lightheadedness, “walking in a fun house”; sense of unsteadiness
Functional dizziness and history
-used to be disregarded
-all structures are intact but not interacting/communicating properly with each other
-20-30% of specialized neurology visits are due to functional problems rather than structural
Proposed pathophysiology of PPD
PREDISPOSAL:
-neurotic temperament
-pre-existing anxiety
PRECIPITANTS:
-vestibular crisis
-medical event
-acute psychological distress
ACUTE ADAPTATION–> leads to reduced recovery
-visual-somatosensory dependence
-high-risk postural control strategies
-environmental vigilance
BEHAVIORAL COMORBIDITY:
-anxiety dods
-depressive dods
-somatic symptom dods
PERPETUATING FACTORS:
-visual dependence
-stiffened postural control
-decreased cortical integration
Changes in brain connectivity and PPPD
Early fMRI studies support concept of visual dependence
* Widespread reduction in connectivity from L hippocampus (spatial navigation) to multiple brain regions (Lee, 2018)
* Conversely, increased connectivity between frontal & occipital cortices in relation to mild state anxiety (Lee, 2018)
-rely more on visual system than vestibular
Problem with functioning of the brain (no structural damage)
Just as real of an issue and reason for symptoms
Treatment for PPPD
1.) medication - SSRI, SNRI
2.) physical therapy - includes strong educational component
-necessary to repeat exposure to a particular environment that spurs on symptoms
–> sensory reweighting, decrease visual dependence and habituation
3.) CBT
Mal de debarquement syndrome characteristics
DEF: perception of motion when stationary and the eyes are open
ONSET: usually after prolonged exposure to motion, such as on a cruise
SIGNS:
-diff adapting back to stable enviro
TREAT:
-meds may help
-focus on somatosensory referencing to vestibular sense
