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Neuro Eval > Vestibular Lecture > Flashcards

Vestibular Lecture Flashcards

1
Q

Flowchart of Vestibular Function

A

Sensory input (vestibular, somatosensation, vision) –> Cerebellum and vestibular nuclei –> motor output (reflexes, postural, eye movement)

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2
Q

Peripheral Components

A
  • Membranous Labyrinth, sits in…
  • Bony Labyrinth, supported by…
  • Perilymph
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3
Q

What is perilymph?

A

Similar to CSF with an increased Na:K ratio

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4
Q

Peripheral (Sensory) components

A
  • 3 Semicircular Canals (SCC): Anterior, Posterior and Horizontal canals
  • 2 Otolith Organs: Utricle and Saccule located within the Vestibule
  • Other important landmarks: 8th Cranial Nerve, Endolymphatic Sac, Round & Oval Windows
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5
Q

Semi Circular Canals

A
  • Oriented in 3 canal planes
  • Each canal is paired with a canal on the opposite side
  • Anterior canal with opposite Posterior canal
  • Two Horizontal canals
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6
Q

Ampullofugal Stimulation

A
  • displacement of cupola away from utricle
  • excitation
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7
Q

Ampullopetal Stimulation

A
  • Displacement of cupola towards utricle
  • inhibition
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8
Q

what is the taller hair cell called?

A

Kinocillium

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9
Q

what is entering the hair cell that causes the channel to open?

A

glutamate and aspartate

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10
Q

Does excitatory stimuli or inhibitory stimuli cause a greater response?

A
  • excitatory
  • If you turn your head very quickly, your inhibiting ear may not be inhibiting enough –> fast motions become a problem
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11
Q

Nystagmus at rest: non-pathologic

A

L: 90 spikes/sec
R: 90 spikes/sec

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12
Q

Nystagmus at rest: pathologic

A

L: 40 spikes/sec
R: 90 spikes/sec
**will feel like you are turning to the right

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13
Q

What are the 2 Otoliths

A

Utricle and Saccule
Oriented in 2 different planes

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14
Q

What do the utricle and saccule detect?

A

linear acceleration and tilt

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15
Q

Is the vestibular nerve considered part of the periphery or central?

A

periphery

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16
Q

Where do afferent signals of the vestibular nerve project?

A
  • From scarpa’s ganglion through the internal auditory canal with cochlear and facial nerve (sensory branch) and labyrinthine artery
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17
Q

Where does superior vestibular nerve go?

A

anterior and horizontal canals
utricle

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18
Q

where does the inferior vestibular nerve go?

A

posterior canal and saccule

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19
Q

Where does the vestibular nerve enter the brainstem?

A

at the ponto-medullary junction
“root entry zone”

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20
Q

what does PICA supply

A

inferior portion of the cerebellar hemispheres
dorsolateral medulla

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21
Q

what does the basilar artery supply?

A

pons

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22
Q

what does the AICA supply?

A

peripheral vestibular system via labyrinthine artery

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23
Q

an ICA stoke is likely to cause what?

A

vestibular issues

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24
Q

From where do nuclei receive input?

A

peripheral vestibular system, vision, and somatosensory afferents

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25
Q

How do the vestibular nuclei process and relay information?

A
  • eye movement control for gaze stability during movement
  • ANS control: BP, arousal
  • Postural Control and Movement: brainstem
  • Cortex for spatial orientation
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26
Q

What does the cerebellum do

A

modulates vestibular reflexes

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27
Q

what does the flocculus do?

A

adjusts/maintains gain of VOR

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28
Q

what does the nodulus do?

A

adjusts duration of VOR and processes otolith information

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29
Q

What is the anterior-superior vermis involved with?

A

vestibule-spinal reflex

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30
Q

VOR

A

stable vision during head motion

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31
Q

Vestibulo-spinal reflex

A

stable body during head motion

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32
Q

Vestibulo-Collic Reflex

A

Stable neck during head motion

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33
Q

What is required in order to prevent retinal slip in VOR?

A
  • velocities of eye movements need to match the velocity of head movement
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34
Q

What is VOR gain equation and what should it be equal to?

A

Eye velocity/head velocity
1

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35
Q

What occurs to the VOR gain when excitation and inhibition isnt working properly?

A

gain is no longer 1
result = retinal slip

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36
Q

Non pathologic push-pull phenomenon for R head turn

A

L: 20
R: 160

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37
Q

Pathologic push-pull phenomenon for R head turn

A

L: 20
R: 90

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38
Q

What is nystagmus?

A
  • distorted vestibular input from one side causing an imbalance in the firing rates which produces a rhythmic oscillatory movement of the eyes
  • usually occurs in pathologic vestibular system
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39
Q

What is vertigo

A

abnormal sensation of illusion of motion

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40
Q

what is alexanders law
you really have to know this

A

vestibular nystagmus increases if the person looks with their eyes toward the past phase of the nystagmus and decreases if eyes are toward the slow phase

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41
Q

Say it again for the people in the back…
What strictures are part of the peripheral vestibular system?

A
  • vestibular end organs (2 semicircular canals and utricle and saccule)
  • vestibular portion of CNVIII
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42
Q

What structures are part of the central vestibular system

A
  • vestibular nuclei
  • vestibulocerebellum
  • vestibuloocular pathway
  • vestibulospinal pathways
  • vestibular areas in the cortex
  • vestibulo-autonomic pathways
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43
Q

Vestibulospinal Reflex

A
  • Medial vestibulospinal tract: MLF to cervical cord –> head movements and integrating head and eye movements
  • Lateral Vestibulospinal tract: To thoracic spinal cord –> head and body position in space for walking
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44
Q

Central Vestibular Function

A
  • Discrimination between self movement vs. that of the environment
  • spatial awareness and perceived vertical
  • “personal space”
  • Visuo-vestibular integration
  • self-motion perception
  • multisensory spatial coding (proprioceptive, auditory, visual, tactile)
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45
Q

Vestibular Connections to autonomic nervous system

A

– Locus coeruleus (stress and panic)
– Nucleus of the solitary tract (Vagus nerve: nausea)
– Area postrema (vomiting)
– Central nucleus of amygdala (emotional memory)
– Parabrachial nucleus (arousal)
– Infralimbic cortex (fear, emotional regulation)
– Hypothalamus (memory, BP, circadian rhythm)

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46
Q

Most common diagnoses in vestibular practice

A

– BPPV
– Vestibular Migraine
– Vestibular Neuritis
– PPPD/Anxiety-related Dizziness
– Meniere’s Disease

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47
Q

Peripheral Diagnoses

A
  • Benign Paroxysmal Positional Vertigo (BPPV)
  • Labyrinthitis/Neuritis
  • Meniere’s Disease (endolymphatic hydrops)
  • S/P Acoustic Schwannoma (Neuroma)
  • Bilateral vestibular loss
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48
Q

Central Diagnoses

A
  • Traumatic Brain Injury/concussion
  • Vestibular Migraine
  • Persistent Postural-Perceptual dizziness (PPPD)
  • Cerebellar disorders
  • Multiple Sclerosis
  • Stroke- brainstem and cerebellar
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49
Q

Non-Vestibular Diagnoses

A
  • Balance disorder
    – orthopedic or neurologic etiology
  • Cervicogenic Dizziness
  • Multisensory Dysequilibrium
50
Q

Other things that can cause dizziness:

A

– Medications
– Cardiac
– Postural hypotension
– Diabetes mellitus
– Thyroid condition
– Renal failure
– Visual changes
– Anxiety

51
Q

what is oscillopsia?

A

a perception of the world bouncing

52
Q

Vestibular Labrynthitis

A
  • Viral>Bacterial infection of the vestibular nerve and labyrinth, sometimes cochlea
  • Typically results in gradual onset spinning, nausea & vomiting, peaking in 24 hours
  • Worst symptoms 5-7 days, following pattern of typical viral infection
  • Often must be in bed first few days as symptoms are severe
  • Hearing loss and vestibular symptoms
  • Residual symptoms may take weeks to resolve
53
Q

Vestibular Neuritis

A
  • Same as Labyrinthitis but primarily affects the vestibular nerve and labyrinth but not cochlea
  • No hearing loss
  • Both neuritis and labyrinthitis often diagnosed by symptoms only, used lavishly
  • Both have no recovery from the impaired side, but CNS compensates for the loss
54
Q

What is Meniere’s disease?

A
  • Disorder caused in theory by too much
    endolymph in the system causing
    membranous distention
  • Endolymphatic sac may be producing too much endolypmh or endolymph not being reabsorbed enough within the labyrinth
  • Affects females>males, mid-life (30-50 at onset)
55
Q

Clinical Presentation of Meniere’s Disease

A
  1. Episodic in nature
  2. Symptoms come on suddenly, lasts from several minutes to a few hours, leaves suddenly
  3. During an episode, will have vestibular testing similar to a unilateral vestibular loss
  4. Between spells, testing will be normal
  5. Fluctuating hearing w/progressive low frequency hearing loss on audiogram
56
Q

Symptoms of Meniere’s disease

A

a. Mild to severe spinning (Nausea & vomiting, Imbalance & falls)
b. Aural fullness, fluctuating hearing
c. Tinnitus

57
Q

Progression of Meniere’s Disease

A

– Early: Symptom free in-between episodes
– Late: Permanent hearing loss and vestibular impairment

58
Q

When is PT indicated for Meniere’s Disease

A

If patient is experiencing imbalance or dizziness in between episodes

59
Q

Treatment for Meniere’s Disease

A

– Low sodium diet/diuretics to attempt to manage fluid imbalance
– Transtympanic gentamycin or steroid injections
– Surgery for endolymphatic shunt, labyrinthectomy

60
Q

What is an Acoustic Schwannoma?

A
  • Nerve sheath tumor occurs on 8th cranial nerve, usually originates from vestibular nerve
  • Benign and usually slow growing
  • Third most common intracranial tumor
61
Q

Where are Acoustic Schwannomas located?

A

internal auditory canal at
cerebellopontine angle

62
Q

Symptoms of Acoustic Schwannomma

A

– Progressive, unilateral hearing loss
– Tinnitus
– Mild dysequilibrium
– Vertigo

**diagnosis confirmed with MRI

63
Q

Treatment for Acoustic Schwannoma

A

– Watchful waiting
– Removal via stereotactic radiosurgery or micro-surgical excision
– Vestibular rehab before and/or following surgery

64
Q

Possible causes of bilateral vestibular loss?

A
  • Ototoxicity
  • Bilateral acoustic neuroma
    (neurofibromatosis)
  • Autoimmune disease
  • Otosclerosis/degeneration
65
Q

Presentation of Bilateral Vestibular Loss

A

– Potential hearing loss
– Significant oscillopsia
– Dysequilibrium in low light, complex visual environment, uneven surfaces
– No significant complaints of dizziness if loss is complete

66
Q

What types of functional impairments are seen with bilateral vestibular loss?

A

– Gait slow, little visual scanning
– Usually requires an assistive device for safety
– High risk for falls due to lack of stability, esp. changes in sensory environments

67
Q

What can cause Central Vestibulopathy?

A
  • Traumatic Brain Injury/concussion
  • Vestibular Migraine
  • Persistent Postural-perceptual Dizziness (PPPD)
  • Cerebellar disorders
  • Multiple Sclerosis
  • Stroke
68
Q

Diagnostic criteria for vestibular migraine

A

– No documented vestibular pathology
– Migraine diagnosis according to International
Headache Society (IHS) criteria- new in 2018
– Can use the Migraine Assessment Tool to help
determine Migraine
– Intermittent vertigo or dysequilibrium- at least
2 episodes
– Accompanied by photo or phonophobia, visual aura, not necessarily headache

69
Q

Vestibular Migraine Overview

A
  • Females > males
  • Can have migraines for years without dizziness, then develop dizziness
  • Prevalence 23.4% of people with dizziness
  • Comorbidity with BPPV and Meniere’s disease
70
Q

What shows the best improvements in balance and vestibular migraine symptoms?

A

Medical management and vestibular rehabilitation

71
Q

Pts with vestibular migraine have difficulty in what types of environments

A

wide open spaces, busy visual environments

72
Q

What is found to be equally effective as meds or relaxation for vestibular migraine

A

exercise

73
Q

intervention strategy for vestibular migraine

A
  • Education!
  • Collaboration with physician to decrease frequency of migraines
  • Intervene with vestibular rehab for signs/symptoms that persist in between migraines
  • No intervention for dizziness that occurs
    during migraine
74
Q

Mild TBI/Concussion

A
  • Impairment may be either peripheral, central, or
    neither
  • Large comorbidity with migraine and anxiety (Concussion causes post-traumatic headache)
  • Autonomic dysfunction can lead to exercise
    intolerance
  • Management involves accurate identification of
    impairment and then appropriate interventions
75
Q

Mild TBI/Concussion Acute Stage management

A

(24-48 hours) involves rest, but then pt.
should be progressed as tolerated

76
Q

Persistent Postural Perceptual Dizziness (PPPD) Presenting Symptoms

A

Anxiety leads to:
- heightened ANS reactivity (constant fight or flight stage)
- decreased tolerance for postural disturbance
- increased sensitivity to visual stimuli
- less flexibility in postural control strategies
- altered integration of sensory information (decreased use of vestibular cues, visual dependence) –> overusing visual for balance
= conundrum and chaos

77
Q

In what positions is there a sensation of imbalance and disequilibrium with PPPD?

A
  • when upright
  • relieved when sitting or lying down
78
Q

symptom of PPPD

A
  • more than 3 months of near daily symptoms
  • balance that feels worse than it is
  • hypersensitivity to motion
79
Q

What is PPPD exacerbated by?

A
  • complex visual environments
  • wide open spaces with shiny floors
  • scrolling
  • reading
  • close visual work
80
Q

What to look for in assessment for PPPD:

A
  • postural stability: pt reported perception of motion/instability
  • greater caution in volitional movements and greater use of cognition
  • no other vestibular or central disorders that can account for symptoms
  • perceived threat: pt feels unsafe during typical functional tasks
  • less flexibility to postural control strategies
  • sensory organization impairment
81
Q

What is the primary symptom of Multisensory Disequilibrium? (AKA Disequilibrium of Aging)

A

imbalance during functional mobility

82
Q

what does Multisensory Disequilibrium result from?

A

degradation of two or more sensory systems responsible for balance
– Bilateral vestibular degeneration
– Peripheral neuropathy
– Visual deficits

83
Q

What is cervicogenic dizziness and how is it diagnosed?

A
  • dizziness and disequilibrium that is associated with neck pain
84
Q

what is the current theory of cervicogenic dizziness?

A

cervical dysfunction causes abnormal input into the vestibular nuclei from the proprioceptors of the upper cervical region

85
Q

Diagnosing Cervicogenesis Dizziness

A
  • Diagnosis of exclusion - no vestibular pathology
  • Close temporal relationship between neck pain and dizziness
  • Previous neck injury or pathology
  • Elimination of other causes of dizziness
  • Cervical Relocation Test can give
    information about cervical proprioceptive deficits
86
Q

Cervicogenic Dizziness Intervention

A
  • manual therapy to address upper cervical trigger points and hypomobility
  • work on cervical strength and proprioception
87
Q

Subjective clinical impression of COVID 19 causing dizziness

A

– Migraine- exacerbated, progression to vestibular
migraine
– Autonomic dysfunction- POTS
– PPPD with medical etiology

88
Q

what is the most common cause of vertigo in pt’s with peripheral vestibular dysfunction

A

BPPV

89
Q

what population is BPPV seen in?

A
  • adults of all ages
  • more common with advanced age
  • rarely seen in children
90
Q

BPPV Pathology

A

– Otoconia from the otolithic organs become dislodged and make their way into one of the semicircular canals
– Biomechanical problem in which one or more of
the semicircular canals is inappropriately excited
* Otoconia sloughs off just like skin
* New otoconia is formed, old sloughs off and absorbed by the endolymph
* Aging- lose the ability to absorb the otoconia before it gets into the canals

91
Q

Common characteristics of BPPV

A

– Vertigo when the head is moved into various positions or head changes occur
– Rolling over in bed, bending over, looking up, lying flat or turning the head
– Sensation of true spinning after position changes that last for seconds to minutes
– Complaints of imbalance or gait problems, especially with head turns

92
Q

In pts with BPPV, when do symptoms and nystagmus fatigue?

A

with repeated stimulation

93
Q

Is BPPV episodic or constant?

A

episodic
lasts < 60 seconds
- usually a “spinning” sensation

94
Q

Etiology of BPPV

A
  • Post-traumatic
  • Post-acute vestibulopathy
  • Idiopathic
  • Meniere’s Disease
  • Migraine
  • Diabetes
95
Q

What causes nystagmus in BPPV?

A
  • Otoconia are dislodged and float into semicircular canal (usually posterior)
  • with head movement, the otoconia move within the canal resulting in abnormal, unilateral stimulation of the particular canal
96
Q

Canalithiasis

A
  • Free-floating debris in the canal
  • Results in transient, brief nystagmus
97
Q

Cupulothisasis

A
  • debris adhered to the cupula and not free-floating
  • Results in sustained nystagmus
98
Q

Hallmark sign of BPPV

A
  • Rotational Nystagmus
99
Q

2 components of BPPV nystagmus

A
  • Torsional: either right or left side
  • Vertical: either up or down in canal
  • direction of nystagmus indicates canal involved
    EXCEPT for horizontal canal involvement
100
Q

What type of nystagmus occurs with horizontal canal involvement?

A

horizontal nystagus

101
Q

geotropic

A
  • beating toward the ground
  • canalithiasis = free floating debris
102
Q

Apogeotrophic/ageotrophic:

A
  • beating away from the ground
  • cupulothiasis: adhered to the cupula
103
Q

what test should you use to assess anterior and posterior canals?

A

dix-hallpike

104
Q

what test should you use to assess horizontal canals

A

roll test

105
Q

Assessment and Interventions Considerations for BPPV

A
  • MUST explain procedure to patient
  • Nausea can occur with episodes –> Cervical cold pack can be helpful in managing nausea
  • Clear the cervical spine –> ROM, pain, neuro changes
  • Name the nystagmus to ensure appropriate
    treatment
  • Complete all tests prior to treatment
106
Q

How to perform right Dix-Hallpike Test

A
  • Patient’s head is moved 45º to right
  • Patient moves to supine and head extended to 30º
  • Look for nystagmus
  • Maintain position for 30-60 seconds
  • Keep head in position & assist patient to sitting, monitor nystagmus
107
Q

Right Posterior Canal Identification

A
  • R Dix-Hallpike: upbeat and R torsional
  • Return to sitting: downbeat and L torsional
108
Q

Right Anterior Canal Identification

A
  • R Dix- Hallpike: Downbeat and R torsional
  • return to sitting: upbeat and L torsional
109
Q

Left Posterior Canal Identification

A
  • R Dix-Hallpike: Upbeat and L torsional
  • Return to sitting: Downbeat and R torsional
110
Q

Roll Test

A
  • Patient is supine with neck flexed to 20-30º
  • Quickly turn head to left, look for nystagmus, hold for 30-60 seconds
  • Come back to center
  • Quickly turn head to right, look for nystagmus, hold for 30-60 seconds
  • Canal involved will be the side which the
    nystagmus is most vigorous, symptoms most
    intense
111
Q

Intervention options for BPPV

A
  • wait and see
  • Brandt- Daroff Exercises (lying down and sitting up in both directions)
  • Canalith Repositioning Maneuver
  • Liberatory Maneuver
112
Q

What intervention technique do you use for Anterior and posterior canal BPPV?

A

CRM

113
Q

what intervention technique do you use for horizontal canal BPPV?

A

Lempert/BBQ Roll

114
Q

CRM - Right Posterior Canal

A
  • Patient goes into right Dix-Hallpike position and holds for 30-60 sec
  • In at least 30 degrees of extension slowly rotate head to left and hold for 30-60 sec
  • Patient rolls to left sidelying and head is turned to 45º so that head is looking down toward floor, hold for 30- 60 sec and slowly sit up from sidelying
  • Make sure to hold onto the patient once in
    sitting
115
Q

Horizontal Canal Repositioning

A
  • Patient starts sitting with head flexed 30º
  • Lie patient down to supine, turn head to affected side, hold 30-60 seconds
  • Turn head away from affected side to middle, 30-60 seconds
  • Turn head quarter turn to unaffected side, 30-60 seconds
  • Maintain head in this position while patient rolls to sidelying
  • Patient then rolls into supine on elbows, head down
  • At this time, maneuver is complete
  • Recommended way to complete maneuver is to continue to roll in the same direction until sidelying, then sit up slowly
116
Q

Post-maneuver instructions

A

– Do not look up or down for a few hours
– You may feel off balance after the repositioning

117
Q

BPPV Management

A
  • most effective if perform multiple repositioning maneuvers in one session (1-3 maneuvers, waiting 5-10 mins every day)
  • do not treat more than every other day unless in acute hospital
  • do not treat multiple canals in one session
  • may need to repeat maneuvers
  • may treat subjective symptoms if they correlate with typical pattern (latency duration)
118
Q

how to decrease nausea/vomiting during BPPV management

A

use cervical cold pack to decrease symptoms

119
Q

Central positional nystagmus is similar in presentation to BPPV except:

A
  • no latency
  • does not fatigue
  • long duration
  • may be apogeotropic (horizontal)
120
Q

Central positional nystagmus vs. BPPV

A
  • Vertical nystagmus may also be present
  • +Nausea/vomiting, even with single maneuver
  • Co-existing cerebellar or central oculomotor signs
  • Lesion of vestibulo-cerebellum-flocculonodular lobe

Neuro Eval (18 decks)

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