Vestibular Part II Flashcards
1
Q
Describe vestibular neuritis
A
- 2nd most common cause of peripheral vertigo
- Onset is often preceded by the presence of a viral infection of the upper respiratory or gastrointestinal tracts
- Associated viral infection may be coincident with the vestibular neuritis or may have preceded it by as long as 2 weeks
- Chief symptom is the acute onset of prolonged severe rotational vertigo that is exacerbated by movement of the head
2
Q
Describe neuritis and labyrinthitis
A
- Neuritis (inflammation of the nerve) affects the branch associated with balance, resulting in dizziness or vertigo but no change in hearing
- Neuronitis (damage to the sensory neurons of the vestibular ganglion) term is also used
- Labyrinthitis (inflammation of the labyrinth) occurs when an infection affects both branches of the vestibulo-cochlear nerve resulting in hearing changes as well as dizziness or vertigo
3
Q
Symptoms associated with the acute onset of severe rotational vertigo
A
- Spontaneous horizontal rotatory nystagmus beating toward the good ear
- Postural imbalance with a tendency to fall toward the affected side
- Nausea
4
Q
Describe H.I.N.T.S.
A
- For patients with acute vestibular syndrome need to rule out central causes indicated by the following clinical findings
- Normal head impulses
- Direction changing nystagmus in different directions of gaze: pure vertical or torsional, not suppressed with visual fixation
- Vertical skew
5
Q
Describe the nystagmus seen with vestibular neuritis
A
- Increased intensity of nystagmus with vision blocked (no fixation)
- Intensity of nystagmus increases with gaze towards unaffected ear, decreases in intensity with gaze towards affected ear (Alexander’s Law)
- If no change in quality of nystagmus with vision blocked, Dx of vestibular neuritis is excluded indicating central lesion
- Positive head impulse
6
Q
Main signs & symptoms with acute or subacute onset of vestibular neuritis
A
- Generally last 24-72 hrs
- Sustained rotatory vertigo
- Horizontal spontaneous nystagmus toward the non-affected ear
- Oscillopsia: blurred vision or movement of visual surrounding
- Gait and postural imbalance: falls toward the affected ear; positive Romberg test
- Nausea and vomiting
7
Q
Complications of vestibular neuritis
A
- Positional dizziness or BPPV (Benign Paroxysmal Positional Vertigo) can also be a secondary type of dizziness that develops from neuritis or labyrinthitis and may recur on its own chronically.
8
Q
Expected course of recovery for vestibular neuritis
A
- Most patients prefer to stay in bed for 1-3 days, and after 1-6 wks are symptom free during slow movements
- Recuperation is dependent on recovery of the vestibular nerve through functional restitution, central compensation, and physical activity
- Central compensation is improved by vestibular rehabilitation.
- Recovery can be complicated by benign paroxysmal positional vertigo that develops within a few weeks in approximately 10 to 15% of patients with vestibular neuritis
9
Q
Describe stroke screening using I.N.F.A.R.C.T.
A
- I.N.: Impulse normal (HIT negative bilaterally)
- F.A.: Fast phase alternating (direction changing nystagmus)
- R.C.T.: Refixation on cover test (skew deviation)
10
Q
Pathway using the H.I.N.T.S. Plus
A
- Definite stroke: CT to exclude hemorrhage before lysis, MRI after
- Probable stroke: <48 hrs post onset = if stable observe or admit, delayed MRI; >48 hrs post onset = MRI from ED to determine disposition
- Vestibular neuritis: treat & discharge (or admit for fluid +/- gait rehab)
11
Q
What are the peripheral findings from the H.I.N.T.S. Plus
A
- Must have ALL of the following
- Unidirectional nystagmus (direction fixed)
- No skew deviation
- Abnormal head impulse: unilateral, away from fast phase of nystagmus
- No new hearing loss
12
Q
What re the central findings from the H.I.N.T.S. Plus
A
- Stroke is suspected if ANY of the following exist
- Normal head impulse
- Direction changing nystagmus in eccentric gaze (gaze evoked nystagmus)
- Skew deviation (vertical ocular misalignment)
- New hearing loss
13
Q
What are the pitfalls and pearls of the H.I.N.T.S Plus
A
- Pitfall: assuming that the HINTS Plus signs apply to any patient with vertigo
- Pearls: HINTS Plus signs are of significant value in pts with acute spontaneous continuous vertigo particularly when they have nystagmus; if no nystagmus pts may need to have at least postural instability to increase the specificity of HINTS
14
Q
Patient complaints with lateral medullary syndrome AKA Wallenburg’s or PICA syndrome
A
- Vertigo/dysequilibrium
- Altered perception of verticality
- Loss of pain & temperature: ipsilateral on face & contralateral on body
15
Q
Clinical findings of lateral medullary syndrome AKA Wallenburg’s or PICA syndrome
A
- Central nystagmus
- Ipsiversive OTR
- Ipsipulsion on saccades
- Lateropulsion of body
- Ipsilateral dysmetria, dysrhythmia, and dysdiadochokinesia
- Ipsilateral Horner’s Syndrome: drooping eyelid, decreased pupil size and decreased sweating on the affected side of face
16
Q
Patient complaints for Lateral Pontomedullary Infarct (AICA infarction)
A
- Vertigo/dysequilibrium
- Altered perception of verticality
- Loss of pain & temperature: ipsilater on face & contralateral on body
- Hearing loss
17
Q
Clinical findings of Lateral Pontomedullary Infarct (AICI infarction)
A
- Similar to lateral medullary infarct
- Gaze evoked (direction changing) nystagmus
- Unilateral hearing loss is more common with AICA than PICA infarcts
18
Q
Describe a cerebellar infarction
A
- Vertebral artery, PICA, or AICA occlusion may result in infarction confined to the cerebellum
- Initial Symptoms: Vertigo, Nausea with vomiting, Ataxia
- May be confused with peripheral vestibular loss: SHOULD SEE CEREBELLAR SIGNS
19
Q
Findings that suggest acute peripheral vestibulopathy (S.E.N.D. H.I.M. O.N. H.O.M.E. S.A.F.E.)
A
- Straight Eyes: no skew deviation
- No Deafness: no new hearing loss on either side
- Head Impulse Misses: unilaterally abnormal head impulse test on the side opposite the fast phase of nystagmus
- One way Nystagmus: predominantly horizontal, direction-fixed in all gaze positions
- Healthy Otic and Mastoid Exam: pearly tympanic membranes, no pimples, pus, perforation, or pain on palpation of the mastoid
- Stands Alone: no balance difficulty in unsupported standing
- Face Even: no facial palsy or weakness
20
Q
What is used as a Ddx for patients presenting to the ED with complaints of isolated vertigo
A
- S.T.A.N.D.I.N.G.
- SponTAneous Nystagmus: present or absent
- Direction: if spontaneous nystagmus is present what direction
- head Impulse test: normal or not
- standiNG: ataxic or unable
- If nystagmus is positional and in the horizontal/sagittal coronal plane we’re thinking BPPV
21
Q
Common causes of triggered episodic vestibular syndrome
A
- Benign paroxysmal positional vertigo
- Postural hypotension
- Perilymph fistula
- Superior canal dehiscence syndrome
- Vertebrobasilar insufficiency
- Central paroxysmal positional vertigo
22
Q
What are the most frequent diagnosis of dizziness in elderly
A
- BPPV
- Uncertain
- BPPV Confirmed
- Non-CNS, Non-Vestibular
- CVA
- Uncertain Vestibular
- Meniere’s Disease
- Bilateral Vestibular Loss
- Vestibular Neuronitis
- Episodic Vertigo
- Sudden Unilateral Hearing Loss
23
Q
Describe BPPV (benign paroxysmal positional vertigo)
A
- A mechanical disorder of the labyrinths in which otoconia become displaced in the semicircular canals and cause asymmetric vestibular excitatory output with head movement contributing to episodic, intense, vertigo related to head position
24
Q
- Possible mechanisms/common risk factors for cause of dislodged otoconia
A
- Increased fluid pressure in the labyrinth
- Migraine induced ischemia
- Head trauma
- Infectious or inflammatory disorders
- Aging: Osteoporosis
- Dehydration
- Hypertension
- Diabetes Mellitus
25
Q
Demographics of BPPV
A
- 50% of people >65 years old with dizziness, will develop BPPV
- Given prevalence of BPPV in the elderly, if pt’s >65 years old complain of dizziness, it’s a good idea to rule out BPPV, even if history does not sound like BPPV
- Women affected more than men (2:1)
- R labyrinth is slightly more often involved than L
- Bilateral involvement can be found in 7.5% (90% are traumatic cases)
- Spontaneous remissions are common, but recurrences can occur, and the condition may trouble the patient intermittently for years with a high recurrence rate of up to 50% within 10 years
26
Q
Define Canalithiasis
A
- A theory for the pathogenesis of BPPV that proposes that there are free-floating particles (otoconia) that have moved from the utricle and collect near the cupula of the affected canal, causing forces in the canal leading to abnormal stimulation of the vestibular apparatus.
27
Q
Define Cupulolithiasis
A
- A theory for the pathogenesis of BPPV that proposes that otoconial debris attached to the cupula of the affected semicircular canal cause abnormal stimulation of the vestibular apparatus.
