Vestibular Examination Flashcards
7 Key Questions for DDX
Start - how/when did it start?
Feel - what does it feel like?
Duration - how long did/do episodes last?
Triggers - what are your triggers?
Migraine - history of migraine?
Aural - ear symptoms? (Tinnitus, fullness, hearing)
Falls - history of falls?
DDX Acronym
S - some/start
F - funny/feel
D - dude/duration
T - taught/triggers
M - me/migraine
A - about/aura
F - falls
Comprehensive Vestib Exam
- MSK - posture, strength (extremities, spine)
- Somatosensory - proprioception, kinesthesia, light touch, localization
- Visual - spontaneous and gaze holding nystagmus, SP, saccades, convergence
- Vestibulo-ocular - VOR and VOR cancellation, head impulse test, dynamic visual acuity
- Positional testing - Dix Hallpike
- Romberg, mCTSIB, DGI/FGA
Cervical Proprioceptive System
Pathway: mechanoreceptors of cervical intervertebral joints and musculature, receptors carry info to vestibular nucleus
Dysfunction: functional blockage of joints irritates mechanoreceptors, abnormal muscle tone skews muscle spindles function
Result: inc or aberrant activity of end organs result in confusion of vestibular system, impulses from cervical proprioceptors do not match incoming info from vestibular system
Presents as nystagmus or vague symptoms
Test of Joint Position Error (JPE)
- Rob Landel JPE chart
- Error of < 4.5 is normal
- At least 3 attempts at bilateral rotation
Pt sits upright at resting position, turns all the way and holds 3s then returns
Why perform oculomotor testing?
- Assess range and control of ocular mvmt
- Determine integrity/function of several pathways of the CNS/PNS
Elements of Oculomotor Exam
-Spontaneous nystagmus (blank background)
-Gaze holding nystagmus (20-30deg horiz/vert, MUST observe if direction changes or fixed)
-Smooth pursuits
-Saccades
-Convergence (blurred or double 6-10cm)
Spontaneous nystagmus present
May be due to central or peripheral lesions. Downbeating = CNS!!
Gaze holding nystagmus present
May be due to a central or peripheral lesion
Smooth pursuit abnormal
Abnormalities with cerebellar or brainstem lesions
Saccades abnormal
Abnormalities usually seen with lesions in brainstem, cerebellum, basal ganglia and cortex
Convergence abnormal
Abnormalities seen with brainstem and occipital lobe lesions
Vestibular Ocular Assessment
-VOR (screen, observation)
-Head impulse test
-Dynamic visual acuity test
-VOR cancellation
VOR Assessment
Ask patient to focus on finger while moving head side-to-side in a “no” movement, then up and down in a “yes” movement. Speed = 2Hz
Look for ability to maintain gaze and symptoms
Head impulse test
Patient seated, ask patient to focus on nose.
Move the patients head side-to-side (slowly),
Then quickly “thrust” the patient’s head 30 degrees from midline
Observe for gaze stability without making a corrective saccade
What position should head be in for horizontal canal movement testing
Chin tucked 30 degrees
What does head impulse test help determine?
Establish laterality for pt with unilateral peripheral deficit.. involved is side that you turn to when they lose fixation
Dynamic visual acuity test
W Snellen chart and metronome, ask pt to read lowest possible line with head still. Then examiner shakes pts head at 2Hz and they read the lowest possible line.
> 3 line difference = VOR deficit
VOR Cancellation
Pt focuses on thumb out front and maintains focus as they rotate their whole body back and forth
If unable to maintain fixation pt can’t cancel VOR, may be cerebellar lesion
BPPV
Otoconia from utricle fall into semicircular canal (usually posterior). Test with Dix Hallpike for short duration torsional/vertical nystagmus. CRM to treat.
