Week 1: Vestibular and Balance Disorders Flashcards
What is the nonspecific term that encompases any and all of the following symptoms- vertigo, imbalance, lightheadedness, combo
Dizziness
What type of vestibular condition? Sudden memorable onset, Typically true vertigo on onset, Paroxysmal spontaneous events
Peripheral (Labyrinthine/VIIIn)
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.)
Central or non-vestibular
Peripheral or Central? Vestibular Neuritis/Labyrinthitis
Peripheral
Peripheral or Central? Disequilibrium of Aging
Central
Peripheral or Central? CVA
Central
Peripheral or Central? Acoustic Neuronma
Peripheral
Peripheral or Central? Meniere’s Disease
Peripheral
Peripheral or Central? BPPV
Peripheral
Peripheral or Central? Migraine
Central
Peripheral or Central? Toxicity
Peripheral
Peripheral or Central? Head Trauma (TBI/Concussion)
Central
What is the most common cause of vertigo?
BPPV
What is the second most common cause of vertigo?
Vestibular neuritis
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
BPPV
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
Vestibular Neuritis
What is the 3rd most common intracranial tumor?
Acoustic neuroma
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
Viral Endolymphatic Labyrinthitis
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
Acoustic Neuroma
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
Meniere’s Disease
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
Toxicity
What is the most common single known cause of bilateral vestibulopathy?
Gentamicin toxicity
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
Dysequilibrium of Aging
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
Vertebrobasical Artery Insufficienct
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).
Bow Hunter’s Syndrome
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
Migraines
How long do auro migraines typically last?
5-20 min
How long to migraines with prolonged auras last?
days to weeks
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
Migraine without aura
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
Migraine with aura
What type of migraine? symptoms include vertigo, tinnitus, decreased hearing and ataxia (loss of coordination)
Basilar migraine
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
Labyrinthine concussion
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
Skull fracture
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
Hemorrhage into labyrinthe
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
Hemorrhage into brainstem
What type of TBI has the possible manifestation of: Fluctuating hearing loss, ataxia, imbalance and may cause perilymphatic fistula
Increased intracranial pressure
If concussions are not cleared in ______ days, referral to vestibular rehab may be warranted.
7-10 days
What percentage of patients have concussion syndromes past 7-10 days?
10-15%
What is post-concussive syndrome diagnosed?
6 weeks
A recent study showed we need to consider the initial symptoms of _________ vs. considering age, sex, LOC, and amnesia when discussing length of recovery?
headaches, dizziness, and fogginess
What type of pursuits are common following concussion?
saccadic pursuits or intrusions
What type of saccades are common following concussion?
hypometric saccades, slowed saccades
What redirects fovea w/ gross or fine conjugate eye movement jumps from pt A to pt B?
Saccades
What tracks a moving target and stabilizes images on fovea?
Pursuits
What moves the eyes in opposite direction to align both foveas on the same object in space?
Vergence
What is ability of eyes to turn inward to focus on a near target?
Convergence
What is the normal near point of convergence?
What is an overt deviation of the eye?
tropia
What is an ocular deviation occuring when dissociation occurs?
phoria
______ is the most common frequently associated with mTBI and characteristzes the vast majority of blast injuries sustained by service members
Axonal injury
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
Orthostatic hypotension
- Vascular Compromise
- Abnormal sensory input from neck proprioceptors
- Cervical Cord Compression
- High Cervical Disease
- Neck’s interaction with other types of vertigo
- Cervicogenic Migraine
Cervicogenic Dizziness
- 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
Ramsay Hunt Syndrome
- 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
Arnold Chiari
- 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
Multiple Sclerosis
- “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%)
Mal De Debarquement
