Vestibular Exam Flashcards
Vestib exam flow
Subjective
Vestibular screen and systems review
HINTS test if they present with ongoing vertigo and with spontaneous nystagmus
Ask contraindications and perform cervical clearing test
Perform cervical ligament testing in supine
Test less affected side first
Dix Hallpike test
Roll test
Side lying test
You only want to do a BPPV exam if the nystagmus presented how?
If the nystagmus and vertigo are only provoked by positional head changes
Why is it important to find out if your patient is on vestibular suppressant medication
Can cause tests to not be sensitive due to masking symptoms
How do we rule out the cardiovascular system
Take vitals
How do we clear the cervical spine/circulation during the systems review?
First ask contras
ROM in all planes, Ask about 5Ds and 3Ns while patient performs.
Next have pt actively rotate to one side then look back behind shoulder and count backward from 10, observe again for 5Ds and 3Ns
What is vertical skew and what does it mean
When the patients head position is not inline with the rest of their body from a vertical standpoint
It is a sign of a central problem
The head thrust test tests for what
How do you perform it?
Tests for peripheral problems
You quickly turn a patients head to one side and watch for the VOR reflex to work normally
What is the HINTS exam?
Head impulse nystagmus test of skew
Tests if the nystagmus is vertical/horizontal and or unidirectional/bidirectional
Good for ruling in a stroke
What are contraindications to doing cervical provocation testing
Hx of neck surgery
Recent neck trauma
Severe RA, upper cervical instability
Cervical myelopathy/radiculopathy
Carotid sinus syncope
Chiari malformation
Vascular dissection syndromes
When conducting the cervical vascular clearing sequence what are we asking our patients if they’re feeling
Dizziness diplopia, dysarthria. Dysphagia, drop attacks
Nystagmus , nausea, numbness and tingling
Which side should you test first first in a vestib exam
Unaffected or less effected side
which portion of the vestib exam would you skip if the cervical screen was not clear?
Definitely don’t do dix-hallpike, may still be able to do roll test and sidelying test
How will nystagmus from cupulolithiasis present during test?
immediate onset of vertigo and nystagmus
Constant intensity as long as they’re in provoking position
How will nystagmus from canalithiasis present during test
Delayed/latent onset of vertigo,nystagmus
symptoms gradually intensify and then subside
lasts for a few seconds to a minute
In what order do you perform the BPPV tests and which canals do they test
Dix-hallpike - Anterior and Posterior (most common)
Roll test- Horizontal
Sidelying test- Posterior and Anterior
What is the patient’s position at the start of the dix-hallpike test
what about at the end?
Longsitting, head turned 45 degrees to one side
Supine, head still 45 degrees to one side but now with 30 degrees of ext aswell
What is the head position to start the roll test?
Pt with head flexed to 30 degrees
During the BPPV tests, Ewalds 1st law states that eye movements are __________________
within the plane of the canal being stimulated
If you see an upbeat (fast phase) with right torsion during a dix-hallpike this indicates which canal
Right posterior
If you see a down-beat (fast phase) with a right torsion during the dix-hallpike this indicates what canal
RIght anterior
If you see an upbeat with a left torsion during the dix-hallpike, what canal?
left posterior
How will a left-anterior canal’s nystagmus present during the dix-hallpike test
left torsional w/ down-beat
What is Ewald’s 3rd law?
Deflection of the cupula towards the canal
(endolymph moving toward the canal from the cupula) creates a stronger response than deflection away from the canal
When going into the test position for dix-hallpike, is the endolymph defecting the cupula towards or away from the canal
towards the canal (stronger excitation according to ewalds law)
When a person complete’s dix-hallpike and returns to sitting, they now have a downbeating nystagmus with L torsional, what does this mean?
R posterior canal
(it’s the opposite of what you’ll see during the dix-hallpike test position)
When a patient with suspected L anterior canalithiasis returns to sitting after the dix-hallpike maneuver, what will you see?
upbeat and R torsional
What goes geotropic nystagmus mean
Apogeotropic?
Geotropic - nystagmus beating towards earth during roll test
apogeotropic - nystagmus beating away from earth during roll test
How long does the patient hold the test-position in a dix-hallpike
1 minute
or until dizziness subsides + 30 seconds
How is the horizontal canal positioned?
30 degrees off of true horizontal
When performing the roll test for HSC BPV, how do you know which side is the involved side
The side that is worst is the involved side
How do you perform the roll test for HSC BPV?
Pt is supine w/ head at 30 degrees flexion
You quickly turn their head 90 degrees and hold the position for 1 minute, then bring their head slowily back to midline and quickly turn to the other side 90 degrees, hold 1 minute again
What is a positive horizontal roll test?
vertigo and nystagmus occur bilaterally w/ one side worse than the other
During the horizontal roll test,
geotropic nystagmus on the more involved side Right side means what
R sided horizontal canal BPPV
When nystagmus is geotropic, the stronger side has canalithiasis
*picture example is for opposite side
During the horizontal roll test towards the R , if you see Apogeotropic nystagmus that is stronger than on the L, what does this tell you
L cupulolithiasis
When nystagmus is apogeotropic, the weaker side has cupulolithiasis
*picture example is for opposite side
how do you perform the sidelying test for PSC or ASC?
have pt turn head 45 degrees to one side, then quickly lay down on side
Can the sidelying test determine the difference between cupulolithiasis and canalithiasis
No, you must first determine this through subjective before the test
If a patient has upbeat nystagmus and rotary component towards down ear in the side lying test, what canal is this?
BPV of downside PSC
Same as in dix-hallpike the PSC is upbeat and ASC is downbeat
If a patient has downbeat nystagmus with rotary component towards down ear, what does this mean?
anterior canal of downside
Same as in dix-hallpike the PSC is upbeat and ASC is downbeat
