Week 1: Vestibular and Balance Disorders

Question 1

What is the nonspecific term that encompases any and all of the following symptoms- vertigo, imbalance, lightheadedness, combo

Answer 1

Dizziness

Question 2

What type of vestibular condition? Sudden memorable onset, Typically true vertigo on onset, Paroxysmal spontaneous events

Answer 2

Peripheral (Labyrinthine/VIIIn)

Question 3

What type of vestibular condition? Sudden onset of vertigo, lightheadedness/imbalance with one of the Ds, Slow onset imbalance standing and walking, Vague symptoms of any character, Slow, vertigo lasting 24/7 (anxiety, etc.)

Answer 3

Central or non-vestibular

Question 4

Peripheral or Central? Vestibular Neuritis/Labyrinthitis

Answer 4

Peripheral

Question 5

Peripheral or Central? Disequilibrium of Aging

Answer 5

Central

Question 6

Peripheral or Central? CVA

Answer 6

Central

Question 7

Peripheral or Central? Acoustic Neuronma

Answer 7

Peripheral

Question 8

Peripheral or Central? Meniere’s Disease

Answer 8

Peripheral

Question 9

Peripheral or Central? BPPV

Answer 9

Peripheral

Question 10

Peripheral or Central? Migraine

Answer 10

Central

Question 11

Peripheral or Central? Toxicity

Answer 11

Peripheral

Question 12

Peripheral or Central? Head Trauma (TBI/Concussion)

Answer 12

Central

Question 13

What is the most common cause of vertigo?

Answer 13

BPPV

Question 14

What is the second most common cause of vertigo?

Answer 14

Vestibular neuritis

Question 15

Key features: brief episodes of vertigo when head is moved in certain positions
Report of symptoms: triggered by lying down, rolling over in bed, bending over, and looking up. Women= hair salon… men= hanging oil under car
Other complaints can include balance problems that may last for hours or days after vertigo stopped, or vague sensations of lightheadedness/feeling of floating

Answer 15

BPPV

Question 16

Definitive etiology is never proven though evidence to support viral in nature.
Characterized by an acute vestibular crisis followed by gradual improvement
Key Features: Vestibular crisis (vertigo, imbalance, nausea) improving over 1-4 days, absence of associated auditory symptoms, head movement sensitivity
Usually affects those 30-60
Gradual and complete recovery is expected
Prognosis is excellent with compensation, vestibular and balance rehab

Answer 16

Vestibular Neuritis

Question 17

What is the 3rd most common intracranial tumor?

Answer 17

Acoustic neuroma

Question 18

Acute vestibular crisis lasting 1-4 days with a history and recovery similar to vestibular neuritis
Key feature is a sudden hearing loss accompanied with vertigo. Hearing loss within a few hours before or after the onset of vertigo (Hearing loss may recover or persist)
If no vertigo reported suspect bilateral loss
Prognosis: excellent for dizziness with compensation and vestibular balance rehab, need immediate steroid tx for hearing loss

Answer 18

Viral Endolymphatic Labyrinthitis

Question 19

Nerve sheath benign tumors arise from Schwann cells lining the axons of the cochleovestibular n.
Causes progressive unilateral hearing loss or tinnitus without vestibular symptoms. Balance issues (if present) tend to be mild and intermittent
Rarely cause acute vestibular crises but may produce syndromes that mimic other vestibular diagnoses.
3 therapeutic options: watchful waiting, radiosurgery and surgical resection

Answer 19

Acoustic Neuroma

Question 20

A disorder of the inner ear function resulting in devastating hearing loss and vestibular symptoms
55% of patient with Meniere’s have migraines
Cause of disease is unknown. Hereditary factors may play a role. Usual onset in the 4th and 6th decades of life, equally between the sexes
Key Features: recurrent, spontaneous spells intense rotational vertigo lasting several hours, postural imbalance, nystagmus, nausea, vomiting, hearing loss, tinnitus and aural fullness. Vertigo will persist anywhere from 30 mins to 24 hours.
Symptoms gradually abate, usually ambulatory within 3 days. Some sensation of unsteadiness will persist but then normal balance returns between spells
Hearing may return to baseline or may have residual permanent sensorineural hearing loss, most common in lower frequencies.
Vestibular exercises are not appropriate unless there is permanent loss of vestibular function, as in the case of surgical destruction of the inner ear or if symptoms between and spells are > 4 weeks apart, Diet and suppressive meds helpful

Answer 20

Meniere’s Disease

Question 21

Often caused by gentamicin
Confirmed by rotary chair test
Symptoms: imbalance and visual symptoms
Imbalance worse in dark or where footing is uncertain
Spinning vertigo is unusual
Visual symptoms are Oscillopsia – only occur when head is moving and Can cause difficulties with driving and with walking

Answer 21

Toxicity

Question 22

What is the most common single known cause of bilateral vestibulopathy?

Answer 22

Gentamicin toxicity

Question 23

A combination of an aging vestibular system, failing or poor vision, and musculoskeletal degeneration can result in balance dysfunction
Unsatisfying to inform patients of no specific cure for their symptoms
Functional capacity can often be meaningful improved with a designed rehab program

Answer 23

Dysequilibrium of Aging

Question 24

Blockages of one or more of the following aa Posterior Inferior Cerebellar (PICA), Vertebral aa., Anterior Inferior Cerebellar (AICA), Basilar a, Superior Cerebellar (SCA)
Can involve episodic vertigo with imbalance with other brainstem signs and symptoms, loss of coordination, ocular motor control deficits as well as postural control and gait abnormalities, speech etc
Treatment: neurology + balance and gait therapy and fall prevention, habituation if symptoms present

Answer 24

Vertebrobasical Artery Insufficienct

Question 25

The vertebral arteries in the neck can be compressed by the vertebrae or other structures.
It is presently considered a problem when there is mechanical compression during head rotation due to muscular and tendinous insertions, osteophytes, and arthritis around the C1-C2 level.
In general, there is a mixed downbeat/torsional/horizontal nystagmus beating towards the compressed vertebral artery (i.e. away from the direction of head turning).

Answer 25

Bow Hunter’s Syndrome

Question 26

Some will develop vertigo as an aura prior to a classic migraine, others present with episodic vertigo without subsequent headache
Studies have shown that people with migraines are more likely to suffer severe motion sickness and may be more likely to suffer from Meniere’s Disease or BPPV

Answer 26

Migraines

Question 27

How long do auro migraines typically last?

Answer 27

5-20 min

Question 28

How long to migraines with prolonged auras last?

Answer 28

days to weeks

Question 29

What type of migraine? consists of periodic headaches that are usually throbbing and one sided, worse with activity, and associated with nausea and increased sensitivity to light and noise. Vertigo can occur before, during or separately from the episodes of migraine headache

Answer 29

Migraine without aura

Question 30

What type of migraine? is associated with short lived symptoms (noises, flashes of light, tingling, numbness, vertigo and others) known as the aura. Symptoms usually precede the headache and usually last 5-20 mins

Answer 30

Migraine with aura

Question 31

What type of migraine? symptoms include vertigo, tinnitus, decreased hearing and ataxia (loss of coordination)

Answer 31

Basilar migraine

Question 32

What type of TBI has the possible manifestation of: Ataxia, imbalance, BPPV may be present and is the most common vestibular injury due to TBI

Answer 32

Labyrinthine concussion

Question 33

What type of TBI has the possible manifestation of: UVL or BVL (partial or complete)
Conductive hearing loss
May have mixed peripheral and central lesions and is common with blows to the occiput, temporal or parietal regions

Answer 33

Skull fracture

Question 34

What type of TBI has the possible manifestation of: May create post traumatic hydrops (Meniere’s type syndrome)
Damage to labyrinth, may create acute vertigo and Unilateral hearing loss

Answer 34

Hemorrhage into labyrinthe

Question 35

What type of TBI has the possible manifestation of: Oculomotor signs, poor smooth pursuit, vertigo, perception of tilt and has damage to vestibular and oculomotor nuclei

Answer 35

Hemorrhage into brainstem

Question 36

What type of TBI has the possible manifestation of: Fluctuating hearing loss, ataxia, imbalance and may cause perilymphatic fistula

Answer 36

Increased intracranial pressure

Question 37

If concussions are not cleared in ______ days, referral to vestibular rehab may be warranted.

Answer 37

7-10 days

Question 38

What percentage of patients have concussion syndromes past 7-10 days?

Answer 38

10-15%

Question 39

What is post-concussive syndrome diagnosed?

Answer 39

6 weeks

Question 40

A recent study showed we need to consider the initial symptoms of _________ vs. considering age, sex, LOC, and amnesia when discussing length of recovery?

Answer 40

headaches, dizziness, and fogginess

Question 41

What type of pursuits are common following concussion?

Answer 41

saccadic pursuits or intrusions

Question 42

What type of saccades are common following concussion?

Answer 42

hypometric saccades, slowed saccades

Question 43

What redirects fovea w/ gross or fine conjugate eye movement jumps from pt A to pt B?

Answer 43

Saccades

Question 44

What tracks a moving target and stabilizes images on fovea?

Answer 44

Pursuits

Question 45

What moves the eyes in opposite direction to align both foveas on the same object in space?

Answer 45

Vergence

Question 46

What is ability of eyes to turn inward to focus on a near target?

Answer 46

Convergence

Question 47

What is the normal near point of convergence?

Question 48

What is an overt deviation of the eye?

Answer 48

tropia

Question 49

What is an ocular deviation occuring when dissociation occurs?

Answer 49

phoria

Question 50

______ is the most common frequently associated with mTBI and characteristzes the vast majority of blast injuries sustained by service members

Answer 50

Axonal injury

Question 51

Symptoms of Dizziness:
o Faintness or lightheadedness which appear only in standing, & which are caused by low blood pressure
o Only rarely is spinning vertigo caused by orthostatsis
o Chest pain
o Sweating/nausea

Answer 51

Orthostatic hypotension

Question 52

• Vascular Compromise
• Abnormal sensory input from neck proprioceptors
• Cervical Cord Compression
• High Cervical Disease
• Neck’s interaction with other types of vertigo
• Cervicogenic Migraine

Answer 52

Cervicogenic Dizziness

Question 53

• Herpetic infection of the VII and VIII cn
• Sudden onset of pain with open sores, loss of hearing with a vestibular crisis event, facial mm weakness
• Treatment: medical antiviral with steroids
• Prognosis: usually left with hearing loss and needs vestibular balance rehab

Answer 53

Ramsay Hunt Syndrome

Question 54

• Episodic to continuous imbalance and lightheadedness exacerbated by hyperextension of neck, double vision on lateral gaze
• Down beating nystagmus in primary gaze usually exacerbated with lateral gaze
• Treatment: neurology/neurosurgery
• Prognosis: post surgery gait and balance therapy

Answer 54

Arnold Chiari

Question 55

• 5-7% will have true vertigo as initial onset symptom
• Others will have lightheadedness or imbalance
• Shows central signs of saccades and pursuit abnormalities, nystagmus
• Treatment: neurological care/vestibular rehab may be useful in exacerbations for imbalance and habituation to motion sensitivity

Answer 55

Multiple Sclerosis

Question 56

• “sickness of disembarkment”
• Prolonged and inappropriate sensations of movement after exposure to motion
• Typically follows a 7 day “sea voyage”.. But also seen after prolonged air trip
• Symptoms: rocking/swaying and imbalance
• Symptoms subside with exposure to “motion”
• Mainly affects women in their mid 40’s (87%)

Answer 56

Mal De Debarquement