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NM III > Vestibular Disorders PPT > Flashcards

Vestibular Disorders PPT Flashcards

1
Q

Symptoms of vestibular dysfunction:

A

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

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2
Q

Dizziness is more common in ____ compared to ____

A

females, males

2.7: 1

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2
Q

dizziness

A

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

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3
Q

vertigo

A

sensation of self motion with no self motion actually occurring

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4
Q

presyncope

A

sensation of impending loss of consciousness

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5
Q

syncope

A

transient loss of consciousness due to transient cerebral hypoperfusion

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6
Q

unsteadiness

A

feeling of being unstable while seated, standing, or walking

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7
Q

What is the name of the approach for examining acute dizziness or vertigo?

A

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)

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8
Q

What are some triggers and benign causes of acute vestibular disorders?

A

TRIGGERS: trauma, toxin exposure

CAUSES: vestibular neuritis- inflamed vestibulocochlear nerve

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9
Q

What are some triggers and benign causes of episodic vestibular disorders?

A

TRIGGER: head motion, change in body position, exertion

BENIGN CAUSE: BPPV, orthostatic hypotension, vestibular migraine

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10
Q

Serious causes of acute and episodic vestibular disorders

A

ACUTE
-ischemic stroke of the lateral brainstem, cerebellum, or inner ear

EPISODIC
-TIA, posterior fossa mass lesion, cardiac arrythmia

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11
Q

What is a common exam to perform to differentiate peripheral vs central vestibular disorder cause?

A

HINTS PLUS

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12
Q

HINTS PLUS exam components

A

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

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13
Q

Nystagmus and Oculomotor examination

A

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

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14
Q

Test of skew

A

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

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15
Q

head impulse test

A

-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

16
Q

Acronym used to help with identifying a central issue:

A

INFARCT

head impulse test - impulse negative bilaterally

nystagmus type - fast-phase alternating (direction changing)

test of skew - refixation during cover test

17
Q

What test should you also perform if you are concerned with vertebral artery dysfunction?

A

5 Ds

dysphagia, dysphonia, dysarthria, dysmetria, diplopia

18
Q

what are two common peripheral pathologies that can be seen in clininc?

A

MOST COMMON
-BPPV: most common cause of vertigo
-vestibular hypofunction

LESS COMMON
-acoustic neuroma
-Meniere’s Disease
-Perilymph fistula

19
Q

Characteristics of vestibular hypofunction:

A

-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

20
Q

Treatment for vestibular hypofunction:

A

MEDS
-antivertigo meds: Meclizine
-anti-nausea meds: Zofran

REHAB
-CPG
-gaze stabilization exercises

21
Q

Acoustic neuroma characteristics:

A

-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

22
Q

Meniere’s Disease Charactertistics:

A

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

23
Q

Superior Canal Dehiscence characteristics

A

-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

24
Q

Central vestibular disorders discussed in class:

A

-PPPD

-MdDS- mal de debarquement syndrome

25
Q

PPPD- persistent postural-perceptual dizziness

A
  • 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

26
Q

Functional dizziness and history

A

-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

27
Q

Proposed pathophysiology of PPD

A

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

28
Q

Changes in brain connectivity and PPPD

A

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

29
Q

Treatment for PPPD

A

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

30
Q

Mal de debarquement syndrome characteristics

A

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

NM III (19 decks)

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